1659773091 NPI number — YAZMIN PENA LCSW

Table of content: YAZMIN PENA LCSW (NPI 1659773091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659773091 NPI number — YAZMIN PENA LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENA
Provider First Name:
YAZMIN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659773091
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4271 SW 137TH CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33175-3783
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-833-8223
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3850 W FLAGLER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORAL GABLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33134-1604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-398-6100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2014

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: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 19637 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 088293 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 06273789 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 114026500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".