Provider Demographics
NPI:1063639748
Name:PENO, BERNARD (CASAC)
Entity Type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:
Last Name:PENO
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3564 84TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-5374
Mailing Address - Country:US
Mailing Address - Phone:718-446-2010
Mailing Address - Fax:
Practice Address - Street 1:9101 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:718-523-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11238101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)