Provider Demographics
NPI:1982825931
Name:PENA, RARDY LEANDRO (BA)
Entity Type:Individual
Prefix:
First Name:RARDY
Middle Name:LEANDRO
Last Name:PENA
Suffix:
Gender:M
Credentials:BA
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 189
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01903-0289
Mailing Address - Country:US
Mailing Address - Phone:781-593-2727
Mailing Address - Fax:
Practice Address - Street 1:103 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-4001
Practice Address - Country:US
Practice Address - Phone:781-593-2727
Practice Address - Fax:781-593-2542
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist