Provider Demographics
NPI:1548684905
Name:PENNYLANE CENTER
Entity type:Organization
Organization Name:PENNYLANE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPEUTIC BEHAVIORAL SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-266-4783
Mailing Address - Street 1:43418 62ND ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-1807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43418 62ND ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-1807
Practice Address - Country:US
Practice Address - Phone:323-304-9466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherMEDI-CAL
CA#=========OtherMEDI-CAL