Provider Demographics
NPI:1972195063
Name:PENA, GENEVIEVE LILLIE (PT,DPT)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:LILLIE
Last Name:PENA
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 WEYHILL DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-5445
Mailing Address - Country:US
Mailing Address - Phone:214-901-2893
Mailing Address - Fax:
Practice Address - Street 1:10640 N RIVERSIDE DR STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-9506
Practice Address - Country:US
Practice Address - Phone:817-431-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1342821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist