Provider Demographics
NPI:1366611089
Name:PENLAND, MICHAEL ROYCE (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROYCE
Last Name:PENLAND
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5002-1 HEWLETTS RUN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409
Mailing Address - Country:US
Mailing Address - Phone:828-230-6749
Mailing Address - Fax:910-399-5628
Practice Address - Street 1:5002-1 HEWLETTS RUN
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409
Practice Address - Country:US
Practice Address - Phone:828-230-6749
Practice Address - Fax:910-399-5628
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1902103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9406987OtherAETNA BEHAVIORAL HEALTH
NCP01192383OtherRR MEDICARE
NC6000769Medicaid
NC0441MOtherBCBSNC
NC2021303,OtherCIGNA BEHAVIORAL HEALTH
NC6000769Medicaid
NC2021303,OtherCIGNA BEHAVIORAL HEALTH