Provider Demographics
NPI:1750139341
Name:PENA MENENDEZ, ADRIAN
Entity type:Individual
Prefix:
First Name:ADRIAN
Middle Name:
Last Name:PENA MENENDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 6TH AVE S APT 3103
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-4304
Mailing Address - Country:US
Mailing Address - Phone:561-344-9778
Mailing Address - Fax:
Practice Address - Street 1:1105 6TH AVE S APT 3103
Practice Address - Street 2:
Practice Address - City:LAKE WORTH BEACH
Practice Address - State:FL
Practice Address - Zip Code:33460-4304
Practice Address - Country:US
Practice Address - Phone:561-344-9778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-342783106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician