Provider Demographics
NPI:1902676588
Name:PENNER, KAIAROSE
Entity Type:Individual
Prefix:
First Name:KAIAROSE
Middle Name:
Last Name:PENNER
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 1:435 BRANNIGAN VILLAGE DR # 3
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-4892
Mailing Address - Country:US
Mailing Address - Phone:336-473-3081
Mailing Address - Fax:
Practice Address - Street 1:435 BRANNIGAN VILLAGE DR # 3
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-4892
Practice Address - Country:US
Practice Address - Phone:336-473-3081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-23-272661106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician