Provider Demographics
NPI:1497311179
Name:PENA PITA, MAYELIN
Entity Type:Individual
Prefix:
First Name:MAYELIN
Middle Name:
Last Name:PENA PITA
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 1:6460 HAYES ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-5846
Mailing Address - Country:US
Mailing Address - Phone:786-675-7319
Mailing Address - Fax:
Practice Address - Street 1:6460 HAYES ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-5846
Practice Address - Country:US
Practice Address - Phone:786-675-7319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-1980211106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106S00000XMedicaid