Provider Demographics
NPI:1114435427
Name:PENA, MAGDA MARLENE
Entity Type:Individual
Prefix:
First Name:MAGDA
Middle Name:MARLENE
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 1:6468 MIAMI LAKES DR E
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2757
Mailing Address - Country:US
Mailing Address - Phone:305-834-0330
Mailing Address - Fax:
Practice Address - Street 1:6468 MIAMI LAKES DR E
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2757
Practice Address - Country:US
Practice Address - Phone:305-834-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-21
Last Update Date:2018-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician