Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health | B6770816 | CA |
NPI | 1477226876 |
---|---|
Provider Name | Tyrone Penny JR. |
First Address | Modesto, CA 95236 |
Second Address | Modesto, CA 95354-2010 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/07/2021 |
Last Update Date | 30/07/2021 |