Provider Demographics
NPI:1265744247
Name:EDGE, REBEKA PENA (BCBA)
Entity type:Individual
Prefix:MRS
First Name:REBEKA
Middle Name:PENA
Last Name:EDGE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16636 BAIRD CIR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-6711
Mailing Address - Country:US
Mailing Address - Phone:253-686-6958
Mailing Address - Fax:
Practice Address - Street 1:6200 LEE VISTA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-5149
Practice Address - Country:US
Practice Address - Phone:754-444-3707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-07
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-10-7144103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst