Provider Demographics
NPI:1013442771
Name:PENA, YANETSY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:YANETSY
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12793 SW 250TH TER
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-9088
Mailing Address - Country:US
Mailing Address - Phone:786-259-2335
Mailing Address - Fax:
Practice Address - Street 1:10000 SW 56TH ST STE 10
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-7161
Practice Address - Country:US
Practice Address - Phone:786-542-5774
Practice Address - Fax:305-470-7486
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA18214235Z00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician