Provider Demographics
NPI:1073174975
Name:PENA, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3837 BEAUVISTA DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1090
Mailing Address - Country:US
Mailing Address - Phone:917-547-8097
Mailing Address - Fax:
Practice Address - Street 1:3837 BEAUVISTA DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-1090
Practice Address - Country:US
Practice Address - Phone:917-547-8097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-22
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT-1807106H00000X
NC1987106H00000X
NYMFT-0000125-0106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist