Provider Demographics
NPI:1710605308
Name:PENA, SARAH GWEN
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:GWEN
Last Name:PENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 SHASTA DR UNIT 23
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-4967
Mailing Address - Country:US
Mailing Address - Phone:707-470-9217
Mailing Address - Fax:
Practice Address - Street 1:299 SHASTA DR UNIT 23
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-4967
Practice Address - Country:US
Practice Address - Phone:707-470-9217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEP3651103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool