Provider Demographics
NPI:1568744050
Name:PENA, CARRIE (DPT)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1661 PARK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-2841
Mailing Address - Country:US
Mailing Address - Phone:952-428-1265
Mailing Address - Fax:952-428-1266
Practice Address - Street 1:1661 PARK RIDGE DR
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2841
Practice Address - Country:US
Practice Address - Phone:952-428-1265
Practice Address - Fax:952-428-1266
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN87282251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics