Provider Demographics
NPI:1275326894
Name:ADDY, PENNEL
Entity type:Individual
Prefix:
First Name:PENNEL
Middle Name:
Last Name:ADDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3229 LIBERTY ELM LN
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-5227
Mailing Address - Country:US
Mailing Address - Phone:802-583-0949
Mailing Address - Fax:
Practice Address - Street 1:319 CIRCLEVIEW DR
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4253
Practice Address - Country:US
Practice Address - Phone:980-258-3094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities