MEDICARE: PENNY HOUGLAND L.I.C.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	885011106	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	001718108	OTHER	WV	MOUNTAIN STATE BLUE CROSS

General Provider Information

NPI Number	:	1043423031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PENNY HOUGLAND L.I.C.S.W.

Provider Business Mailing Address
First Line	:	909 HARRIS AVE
Second Line	:	STE 201H
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-7080
Country	:	US
Telephone Number	:	360-758-4234
Fax Number	:	360-758-4234

Provider Business Practice Location Address
First Line	:	909 HARRIS AVE
Second Line	:	STE 201H
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-7080
Country	:	US
Telephone Number	:	360-758-4234
Fax Number	:	360-758-4234

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	09/09/2016

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Directions to “ PENNY HOUGLAND L.I.C.S.W.” Practice Location

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