Provider Demographics
NPI:1891336939
Name:PENA, SERGIO (CDPT)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1452
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-1223
Mailing Address - Country:US
Mailing Address - Phone:509-543-1415
Mailing Address - Fax:509-546-0520
Practice Address - Street 1:1175 CARONDELET DR
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99354-3300
Practice Address - Country:US
Practice Address - Phone:509-543-1415
Practice Address - Fax:509-736-3893
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60950451101YA0400X
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)