Provider Demographics
NPI:1689851750
Name:PENA, MELISSA B (OT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:B
Last Name:PENA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 E DOVE AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-2241
Mailing Address - Country:US
Mailing Address - Phone:956-661-0111
Mailing Address - Fax:956-661-0112
Practice Address - Street 1:518 E DOVE AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-2241
Practice Address - Country:US
Practice Address - Phone:956-661-0111
Practice Address - Fax:956-661-0112
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112638225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149229001Medicaid