Provider Demographics
NPI:1669613642
Name:DA PENA, EILEEN (PSYD)
Entity type:Individual
Prefix:DR
First Name:EILEEN
Middle Name:
Last Name:DA 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:PO BOX 025724 PTY 1457
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33192-0001
Mailing Address - Country:US
Mailing Address - Phone:210-209-9188
Mailing Address - Fax:
Practice Address - Street 1:2250 NW 114TH AVE
Practice Address - Street 2:UNIT 1P, PTY 1457
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33192
Practice Address - Country:US
Practice Address - Phone:210-209-9188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-20
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19674103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty