Provider Demographics
NPI:1750379251
Name:PENA, EDDA (LMHC)
Entity type:Individual
Prefix:
First Name:EDDA
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 NE 125TH STREET
Mailing Address - Street 2:SUITE 409
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5834
Mailing Address - Country:US
Mailing Address - Phone:888-852-6672
Mailing Address - Fax:305-503-7363
Practice Address - Street 1:11440 N. KENDALL DRIVE
Practice Address - Street 2:SUITE 208
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1024
Practice Address - Country:US
Practice Address - Phone:888-852-6672
Practice Address - Fax:305-279-2742
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4002101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002409900Medicaid