Provider Demographics
NPI:1245877240
Name:PENA, IVAN
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1738 S TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-5309
Mailing Address - Country:US
Mailing Address - Phone:760-439-2800
Mailing Address - Fax:
Practice Address - Street 1:1738 S TREMONT ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5309
Practice Address - Country:US
Practice Address - Phone:760-547-1381
Practice Address - Fax:760-231-5574
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11940101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional