Provider Demographics
NPI:1801308747
Name:PENA, BLANCA ESTELA
Entity type:Individual
Prefix:
First Name:BLANCA
Middle Name:ESTELA
Last Name:PENA
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 1:875 S ORCHARD AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-7448
Mailing Address - Country:US
Mailing Address - Phone:415-583-7564
Mailing Address - Fax:
Practice Address - Street 1:516 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5410
Practice Address - Country:US
Practice Address - Phone:415-583-7564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA114429101Y00000X, 171M00000X, 225C00000X
101YM0800X
CA138765106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor