=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114475993
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOYLYNN COMIA PENALOZA PSY.D., LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2016
-----------------------------------------------------
Last Update Date | 03/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2211 SE 149TH AVE
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98683-8516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-600-5812
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2211 SE 149TH AVENUE
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98683-8516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-600-5812
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LH60152239
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------