Provider Demographics
NPI:1205380144
Name:PENA, MAYDELIS
Entity Type:Individual
Prefix:
First Name:MAYDELIS
Middle Name:
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 1:1550 W 84TH ST STE 58
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3379
Mailing Address - Country:US
Mailing Address - Phone:305-985-6122
Mailing Address - Fax:
Practice Address - Street 1:2119 NE 36TH TER
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-3245
Practice Address - Country:US
Practice Address - Phone:239-214-4128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT24034225X00000X
FLOTA15338252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No252Y00000XAgenciesEarly Intervention Provider Agency