Provider Demographics
NPI:1003330762
Name:PENA, JOHANNY Y (LMSW)
Entity Type:Individual
Prefix:MS
First Name:JOHANNY
Middle Name:Y
Last Name:PENA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JOHANNY
Other - Middle Name:Y
Other - Last Name:PENA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:54 GROVE ST # 2
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-4123
Mailing Address - Country:US
Mailing Address - Phone:347-852-1407
Mailing Address - Fax:
Practice Address - Street 1:239 N BROADWAY
Practice Address - Street 2:
Practice Address - City:SLEEPY HOLLOW
Practice Address - State:NY
Practice Address - Zip Code:10591-2674
Practice Address - Country:US
Practice Address - Phone:347-852-1407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY100641-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid