Provider Demographics
NPI:1801375472
Name:PENA, EMANUEL (COTA)
Entity Type:Individual
Prefix:
First Name:EMANUEL
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 N EBONY AVE
Mailing Address - Street 2:
Mailing Address - City:ROMA
Mailing Address - State:TX
Mailing Address - Zip Code:78584-8153
Mailing Address - Country:US
Mailing Address - Phone:956-437-0184
Mailing Address - Fax:
Practice Address - Street 1:2530 CENTRAL PALM DR
Practice Address - Street 2:
Practice Address - City:RIO GRANDE CITY
Practice Address - State:TX
Practice Address - Zip Code:78582-6648
Practice Address - Country:US
Practice Address - Phone:956-487-3996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211293224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant