MEDICARE: PAMELA PENROSE LCMHC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1407635543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA PENROSE LCMHC

Provider Business Mailing Address
First Line	:	4670 BLUE STAR RUN APT 308
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28411-0522
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4622 CEDAR AVE STE 122
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-4481
Country	:	US
Telephone Number	:	910-408-2558
Fax Number	:

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

Provider Enumeration Date	:	09/27/2023
Last Update Date	:	06/29/2026

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