Healthcare Provider Details

I. General information

NPI: 1831402304
Provider Name (Legal Business Name): ANDREW MICHAEL PENNER PLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 E 18TH ST STE. 104
HIGGINSVILLE MO
64037-1358
US

IV. Provider business mailing address

14 E 18TH ST STE. 104
HIGGINSVILLE MO
64037-1358
US

V. Phone/Fax

Practice location:
  • Phone: 660-584-5560
  • Fax: 660-584-5562
Mailing address:
  • Phone: 660-584-5560
  • Fax: 660-584-5562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2010023789
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: