Provider Demographics
NPI:1003472440
Name:MINO PENA, TOMAS D (CDPT60922995)
Entity Type:Individual
Prefix:
First Name:TOMAS
Middle Name:D
Last Name:MINO PENA
Suffix:
Gender:M
Credentials:CDPT60922995
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 NW CHEHALIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2010
Mailing Address - Country:US
Mailing Address - Phone:360-948-0203
Mailing Address - Fax:360-262-6703
Practice Address - Street 1:151 N MARKET BLVD STE C
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2677
Practice Address - Country:US
Practice Address - Phone:360-948-0203
Practice Address - Fax:360-262-6703
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1376696096101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)