Healthcare Provider Details

I. General information

NPI: 1184661084
Provider Name (Legal Business Name): DONALD PENZIEN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 11/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5808
  • Fax: 601-815-4710
Mailing address:
  • Phone: 336-716-2255
  • Fax: 336-716-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number28-387
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5203
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: