Healthcare Provider Details

I. General information

NPI: 1366017022
Provider Name (Legal Business Name): TERENCE MATTHEW PENN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SULGRAVE AVE
BALTIMORE MD
21209-3654
US

IV. Provider business mailing address

250 MISSION BLVD UNIT 704
BALTIMORE MD
21230-5627
US

V. Phone/Fax

Practice location:
  • Phone: 443-708-5856
  • Fax: 667-212-5095
Mailing address:
  • Phone: 256-541-1609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number07078
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: