Provider Demographics
NPI:1740081322
Name:PENA, EDITH
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:PENA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 SE 7TH ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009
Mailing Address - Country:US
Mailing Address - Phone:718-664-0255
Mailing Address - Fax:
Practice Address - Street 1:118 SE 7TH ST
Practice Address - Street 2:310
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-3300
Practice Address - Country:US
Practice Address - Phone:718-664-0255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-402540106S00000X, 106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician