Basic Information
| Provider Information | |||||||||
| NPI: | 1366017022 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENN | ||||||||
| FirstName: | TERENCE | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 YEAMANS ST APT 310 | ||||||||
| Address2: | |||||||||
| City: | REVERE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021513440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565411609 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15 PARKMAN ST # 812 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021143117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177248017 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2021 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.