Provider Demographics
NPI:1679076509
Name:PENEBAKER, COURTNEY ANNE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ANNE
Last Name:PENEBAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 W OAK AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4929
Mailing Address - Country:US
Mailing Address - Phone:559-625-2995
Mailing Address - Fax:559-625-4729
Practice Address - Street 1:1425 EAST WALNUT
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93292
Practice Address - Country:US
Practice Address - Phone:559-625-0440
Practice Address - Fax:559-625-4729
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1294550318101YA0400X
CACI31061020101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)