Provider Demographics
NPI:1730951328
Name:SHALD, PENNY LYNN (PROVISIONAL LICENSE)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:LYNN
Last Name:SHALD
Suffix:
Gender:F
Credentials:PROVISIONAL LICENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 E FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:ONEILL
Mailing Address - State:NE
Mailing Address - Zip Code:68763-1844
Mailing Address - Country:US
Mailing Address - Phone:402-336-7452
Mailing Address - Fax:
Practice Address - Street 1:614 N 4TH ST
Practice Address - Street 2:
Practice Address - City:ONEILL
Practice Address - State:NE
Practice Address - Zip Code:68763-1303
Practice Address - Country:US
Practice Address - Phone:402-336-1306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13678101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health