Provider Demographics
NPI:1659147007
Name:PENA, ROSA (BCBA)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 INFIELD CT
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8026
Mailing Address - Country:US
Mailing Address - Phone:704-799-6824
Mailing Address - Fax:704-799-6825
Practice Address - Street 1:280 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1588
Practice Address - Country:US
Practice Address - Phone:704-799-6824
Practice Address - Fax:704-799-6825
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-23-69585103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst