Healthcare Provider Details

I. General information

NPI: 1932408010
Provider Name (Legal Business Name): PENNIE J CARNES LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PENNIE KAY JOHNSON LCP-INTERN

II. Dates (important events)

Enumeration Date: 03/15/2011
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 EAST MAIN STREET
CROSBY MN
56441
US

IV. Provider business mailing address

320 EAST MAIN STREET
CROSBY MN
56441
US

V. Phone/Fax

Practice location:
  • Phone: 218-546-7000
  • Fax: 218-546-4400
Mailing address:
  • Phone: 218-546-7000
  • Fax: 218-546-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number67566
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2155
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: