Provider Demographics
NPI:1053992214
Name:PENROD, LONNIE DALE (MA, MSW, DMIN, LCSW)
Entity type:Individual
Prefix:DR
First Name:LONNIE
Middle Name:DALE
Last Name:PENROD
Suffix:
Gender:M
Credentials:MA, MSW, DMIN, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 ROOSTER ST
Mailing Address - Street 2:
Mailing Address - City:INDIAN MOUND
Mailing Address - State:TN
Mailing Address - Zip Code:37079-5302
Mailing Address - Country:US
Mailing Address - Phone:931-980-4551
Mailing Address - Fax:
Practice Address - Street 1:109 ROOSTER ST
Practice Address - Street 2:
Practice Address - City:INDIAN MOUND
Practice Address - State:TN
Practice Address - Zip Code:37079-5302
Practice Address - Country:US
Practice Address - Phone:931-980-4551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN61951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical