Provider Demographics
NPI:1033851845
Name:GONZALEZ PENA, MAYRETH (RN, CBHCMS)
Entity Type:Individual
Prefix:
First Name:MAYRETH
Middle Name:
Last Name:GONZALEZ PENA
Suffix:
Gender:F
Credentials:RN, CBHCMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8306 COMMERCE WAY APT 241
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1610
Mailing Address - Country:US
Mailing Address - Phone:786-398-1366
Mailing Address - Fax:
Practice Address - Street 1:14505 COMMERCE WAY STE 750
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-1514
Practice Address - Country:US
Practice Address - Phone:305-362-9989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCMS101245171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator