Provider Demographics
NPI:1043731854
Name:PENA, JUAN B (LCSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:B
Last Name:PENA
Suffix:
Gender:M
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17501 SW 152ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33187-6311
Mailing Address - Country:US
Mailing Address - Phone:347-688-3672
Mailing Address - Fax:
Practice Address - Street 1:17501 SW 152ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33187-6311
Practice Address - Country:US
Practice Address - Phone:347-688-3672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075036-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical