Provider Demographics
NPI:1437588837
Name:PENA, ARIAM IVETTE (MA)
Entity Type:Individual
Prefix:
First Name:ARIAM
Middle Name:IVETTE
Last Name:PENA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 JIMMY CARTER BLVD APT 815
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-5082
Mailing Address - Country:US
Mailing Address - Phone:470-351-8219
Mailing Address - Fax:
Practice Address - Street 1:4300 JIMMY CARTER BLVD APT 815
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-5082
Practice Address - Country:US
Practice Address - Phone:470-351-8219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007815101YM0800X
GALPC013366101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303295Medicaid