Provider Demographics
NPI:1477984581
Name:PENA, KATHERINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
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 1:9900 GILMORE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47448-9731
Mailing Address - Country:US
Mailing Address - Phone:812-322-0313
Mailing Address - Fax:812-610-1814
Practice Address - Street 1:9900 GILMORE RIDGE RD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IN
Practice Address - Zip Code:47448-9731
Practice Address - Country:US
Practice Address - Phone:812-322-0313
Practice Address - Fax:812-610-1814
Is Sole Proprietor?:No
Enumeration Date:2013-11-29
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
IN1-18-30049103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist