Healthcare Provider Details

I. General information

NPI: 1407635543
Provider Name (Legal Business Name): PAMELA PENROSE LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2023
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4622 CEDAR AVE STE 122
WILMINGTON NC
28403-4481
US

IV. Provider business mailing address

4622 CEDAR AVE
WILMINGTON NC
28403-4480
US

V. Phone/Fax

Practice location:
  • Phone: 910-408-2558
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: