Provider Demographics
NPI:1801406566
Name:PENA, GABRIEL
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 S DIXIE HWY STE 3
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-4652
Mailing Address - Country:US
Mailing Address - Phone:561-619-5858
Mailing Address - Fax:561-423-8228
Practice Address - Street 1:720 S DIXIE HWY STE 3
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-4652
Practice Address - Country:US
Practice Address - Phone:561-619-5858
Practice Address - Fax:561-423-8228
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH18419101YM0800X
FLMH19879101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health