Provider Demographics
NPI:1083133813
Name:DE LA PENA, AVERY KRISTIE (MSOT, OTR)
Entity Type:Individual
Prefix:MRS
First Name:AVERY
Middle Name:KRISTIE
Last Name:DE LA PENA
Suffix:
Gender:F
Credentials:MSOT, OTR
Other - Prefix:
Other - First Name:AVERY
Other - Middle Name:KRISTIE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7631 PONDEROSA PNE
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78015-5141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 SCENIC LOOP RD # 200D
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-8672
Practice Address - Country:US
Practice Address - Phone:830-755-0098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118625225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics