Healthcare Provider Details

I. General information

NPI: 1568307858
Provider Name (Legal Business Name): PENNY LANISE ADAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28150 VALLEY FORGE ST
SOUTHFIELD MI
48076-5593
US

IV. Provider business mailing address

28150 VALLEY FORGE ST
SOUTHFIELD MI
48076-5593
US

V. Phone/Fax

Practice location:
  • Phone: 313-377-8817
  • Fax:
Mailing address:
  • Phone: 313-377-8817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451013869
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: