Provider Demographics
NPI:1609076603
Name:PENA, HUMBERTO JR
Entity Type:Individual
Prefix:
First Name:HUMBERTO
Middle Name:
Last Name:PENA
Suffix:JR
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 1:10910 BROCKS GAP ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-1715
Mailing Address - Country:US
Mailing Address - Phone:956-208-2681
Mailing Address - Fax:
Practice Address - Street 1:10910 BROCKS GAP ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-1715
Practice Address - Country:US
Practice Address - Phone:956-208-2681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX340692355S0801X
TX0-15-6734103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst