Healthcare Provider Details

I. General information

NPI: 1568404028
Provider Name (Legal Business Name): ROBERT WAYNE PENTON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 S WILLIS ST STE.213
ABILENE TX
79605-4068
US

IV. Provider business mailing address

1290 S WILLIS ST STE.213
ABILENE TX
79605-4068
US

V. Phone/Fax

Practice location:
  • Phone: 325-690-1979
  • Fax: 325-690-1979
Mailing address:
  • Phone: 325-690-1979
  • Fax: 325-690-1979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10118
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: