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General NPI Number Information
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NPI Number | 1437763018
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Entity Type | Individual
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Provider Name | LEE THOMAS PENN
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Gender | Male
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Dates
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Enumeration Date | 09/01/2020
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Last Update Date | 09/18/2020
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Provider Practice Location Address
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Address Line | 2100 N MAIN ST STE 304
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City | CROWN POINT
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State | IN
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Zip | 46307-1877
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Country | US
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Telephone | 888-837-5440
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Fax | 574-546-1999
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Provider Business Mailing Address
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Address Line | PO BOX 10299
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City | FORT WAYNE
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State | IN
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Zip | 46851-0299
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Country | US
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Telephone | 574-546-1900
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Fax | 574-546-1999
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 263320
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 20043365A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 20043365A
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License Number State | IN
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