Provider Demographics
NPI:1366037772
Name:PENA, BEATRIZ
Entity Type:Individual
Prefix:
First Name:BEATRIZ
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 1:19585 NW 55TH CIRCLE PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-6184
Mailing Address - Country:US
Mailing Address - Phone:786-406-4805
Mailing Address - Fax:
Practice Address - Street 1:19585 NW 55TH CIRCLE PL
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-6184
Practice Address - Country:US
Practice Address - Phone:786-406-4805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022499400Medicaid