MEDICARE: KELLI PENNER M.S., LMFT 79102

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	106H00000X	Marriage & Family Therapist	IMF 65537	CA
2	106H00000X	Marriage & Family Therapist	LMFT 79102	CA

General Provider Information

NPI Number	:	1568694966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI PENNER M.S., LMFT 79102

Provider Business Mailing Address
First Line	:	PO BOX 91081
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91109-1081
Country	:	US
Telephone Number	:	323-485-0189
Fax Number	:

Provider Business Practice Location Address
First Line	:	5314 N FIGUEROA ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90042-4004
Country	:	US
Telephone Number	:	626-765-1165
Fax Number	:

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

Provider Enumeration Date	:	08/18/2009
Last Update Date	:	12/13/2021

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