Provider Demographics
NPI:1518701002
Name:PENSON, WILLIE CHARLES KHAALIQ
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:CHARLES KHAALIQ
Last Name:PENSON
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 1:7736 THORNCROFT CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-1906
Mailing Address - Country:US
Mailing Address - Phone:614-500-1555
Mailing Address - Fax:
Practice Address - Street 1:7736 THORNCROFT CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-1906
Practice Address - Country:US
Practice Address - Phone:614-500-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator