Provider Demographics
NPI:1255677290
Name:PENA, SHANNON MICHELLE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
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 1:910 BEACON ST NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-7835
Mailing Address - Country:US
Mailing Address - Phone:321-334-7417
Mailing Address - Fax:
Practice Address - Street 1:12333 NW 18TH ST STE 5
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-4386
Practice Address - Country:US
Practice Address - Phone:954-780-6093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-19
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW216181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical