MEDICARE: TIM PENROD LMFT

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	LMFT-10224	AZ

General Provider Information

NPI Number	:	1659781987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIM PENROD LMFT

Provider Business Mailing Address
First Line	:	10439 S 51ST ST STE 100
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85044-5224
Country	:	US
Telephone Number	:	480-635-9944
Fax Number	:	480-635-9987

Provider Business Practice Location Address
First Line	:	10439 S 51ST ST STE 100
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85044-5224
Country	:	US
Telephone Number	:	480-635-9944
Fax Number	:	480-635-9987

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

Provider Enumeration Date	:	05/08/2014
Last Update Date	:	05/08/2014

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