Provider Demographics
NPI:1740991827
Name:PENA HIDALGO, LIDIANYS
Entity type:Individual
Prefix:
First Name:LIDIANYS
Middle Name:
Last Name:PENA HIDALGO
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 1:732 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33405-1440
Mailing Address - Country:US
Mailing Address - Phone:561-601-1322
Mailing Address - Fax:
Practice Address - Street 1:732 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33405-1440
Practice Address - Country:US
Practice Address - Phone:561-601-1322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22-242203106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician