Provider Demographics
NPI:1457571085
Name:PENA, NICELIA RAQUEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NICELIA
Middle Name:RAQUEL
Last Name:PENA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SO23 CALLE LIMA
Mailing Address - Street 2:VALLE HERMOSO
Mailing Address - City:HORMIGUEROS
Mailing Address - State:PR
Mailing Address - Zip Code:00660-1230
Mailing Address - Country:US
Mailing Address - Phone:787-452-3612
Mailing Address - Fax:
Practice Address - Street 1:FLAMBOYAN 237
Practice Address - Street 2:
Practice Address - City:LAJAS
Practice Address - State:PR
Practice Address - Zip Code:00667
Practice Address - Country:US
Practice Address - Phone:787-809-1835
Practice Address - Fax:787-899-5141
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2496103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical