Basic Information
| Provider Information | |||||||||
| NPI: | 1083055909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENNINGTON | ||||||||
| FirstName: | THOMAS | ||||||||
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| Credential: | MBA, LCAC, CADAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 N TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473043988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | 7657410335 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 E MAIN ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473744358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659355390 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 87000619A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 87000619A | 01 | IN | IN LICENSE | OTHER |