Basic Information
| Provider Information | |||||||||
| NPI: | 1629375571 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENNY | ||||||||
| FirstName: | CARISSA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2740 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720346141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013295459 | ||||||||
| FaxNumber: | 5013271738 | ||||||||
| Practice Location | |||||||||
| Address1: | 6025 SPORTS VILLAGE RD | ||||||||
| Address2: | |||||||||
| City: | FRISCO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750333505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146879374 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2011 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 2441 | TX | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.