Provider Demographics
NPI:1093370744
Name:PENA, STEPHANIE NICOLE (MOT)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:PENA
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2254 MIRASOL ST
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-8409
Mailing Address - Country:US
Mailing Address - Phone:956-293-1128
Mailing Address - Fax:
Practice Address - Street 1:1020 CENTRAL PKWY S
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-5021
Practice Address - Country:US
Practice Address - Phone:210-798-2273
Practice Address - Fax:210-495-1479
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119939225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist