Provider Demographics
NPI:1053441519
Name:PENA, MARIAN ROSE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:ROSE
Last Name:PENA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11049 WHEELER DR
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-9752
Mailing Address - Country:US
Mailing Address - Phone:707-277-0346
Mailing Address - Fax:
Practice Address - Street 1:15230 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8107
Practice Address - Country:US
Practice Address - Phone:707-995-4500
Practice Address - Fax:707-995-2401
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS167041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical