Provider Demographics
NPI:1558004317
Name:PENA, BRANDON LOUIS
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:LOUIS
Last Name:PENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3124
Mailing Address - Country:US
Mailing Address - Phone:562-595-1159
Mailing Address - Fax:562-486-4661
Practice Address - Street 1:222 W 6TH ST STE 230
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3332
Practice Address - Country:US
Practice Address - Phone:310-833-3135
Practice Address - Fax:310-707-2877
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA131236106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist