Provider Demographics
NPI:1639806763
Name:PENA SERRANO, EMMANUEL JOSE (PHD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:JOSE
Last Name:PENA SERRANO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 10339
Mailing Address - Street 2:
Mailing Address - City:OROCOVIS
Mailing Address - State:PR
Mailing Address - Zip Code:00720-9605
Mailing Address - Country:US
Mailing Address - Phone:787-579-7120
Mailing Address - Fax:
Practice Address - Street 1:CALLE GEORGETOWN, NO. 1000
Practice Address - Street 2:APT. 2, UNIVERSITY GARDENS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00927
Practice Address - Country:US
Practice Address - Phone:787-579-7120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7224103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical