Provider Demographics
NPI:1093964074
Name:PENA, MICHAEL ANDREW (LMSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:PENA
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 CERRILLOS RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3373
Mailing Address - Country:US
Mailing Address - Phone:505-438-0010
Mailing Address - Fax:505-438-6011
Practice Address - Street 1:2325 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3373
Practice Address - Country:US
Practice Address - Phone:505-438-0010
Practice Address - Fax:505-438-6011
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-07637104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11479264Medicaid
NM18677037Medicaid