Provider Demographics
NPI:1649990599
Name:PENA, MARTHA ELENA
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:ELENA
Last Name:PENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 WOODBRIDGE LAKES CIR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-5648
Mailing Address - Country:US
Mailing Address - Phone:561-721-5572
Mailing Address - Fax:
Practice Address - Street 1:1521 FOREST HILL BLVD STE 3
Practice Address - Street 2:
Practice Address - City:LAKE CLARKE SHORES
Practice Address - State:FL
Practice Address - Zip Code:33406-6031
Practice Address - Country:US
Practice Address - Phone:561-444-2814
Practice Address - Fax:561-444-2458
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-231769106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician