1053507616 NPI number — MRS. ANGELA EVA PENA LMSW, CBIS

Table of content: MRS. ANGELA EVA PENA LMSW, CBIS (NPI 1053507616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053507616 NPI number — MRS. ANGELA EVA PENA LMSW, CBIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENA
Provider First Name:
ANGELA
Provider Middle Name:
EVA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW, CBIS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SPAGNUOLO
Provider Other First Name:
ANGELA
Provider Other Middle Name:
EVA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053507616
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1806 LINDY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48917-9734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-940-0905
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1806 LINDY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48917-9734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-940-0905
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/18/2007

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: 1041C0700X , with the licence number:  6801089519 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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