Provider Demographics
NPI:1972935138
Name:PENA, GINO FRANCESCO (MSED)
Entity Type:Individual
Prefix:
First Name:GINO
Middle Name:FRANCESCO
Last Name:PENA
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 MELISSA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2605
Mailing Address - Country:US
Mailing Address - Phone:631-525-3415
Mailing Address - Fax:
Practice Address - Street 1:6 MELISSA DR
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2605
Practice Address - Country:US
Practice Address - Phone:631-525-3415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY701656131103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst