Provider Demographics
NPI:1083128169
Name:DE LA PENA, BEATRICE (CDCA)
Entity Type:Individual
Prefix:
First Name:BEATRICE
Middle Name:
Last Name:DE LA PENA
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 NOTRE DAME CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035
Mailing Address - Country:US
Mailing Address - Phone:440-406-7495
Mailing Address - Fax:440-246-0189
Practice Address - Street 1:2202 PRAME AVE.
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109
Practice Address - Country:US
Practice Address - Phone:216-459-1222
Practice Address - Fax:216-459-2696
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-28
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.141534101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCDCA.141534OtherLICENSE