1659200145 NPI number — MRS. DESIREE MAILENE PENA MALLETT PTA

Table of content: MRS. DESIREE MAILENE PENA MALLETT PTA (NPI 1659200145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659200145 NPI number — MRS. DESIREE MAILENE PENA MALLETT PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENA MALLETT
Provider First Name:
DESIREE
Provider Middle Name:
MAILENE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PENA
Provider Other First Name:
DESIREE
Provider Other Middle Name:
MAILENE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PTA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659200145
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
148 RAVELLO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBERTY HILL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78642-2306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 W BEN WHITE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78704-8095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-730-4800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2026

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225200000X , with the licence number:  2165191 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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