Provider Demographics
NPI:1811638299
Name:PENA, YAMELLY E (MA)
Entity type:Individual
Prefix:MISS
First Name:YAMELLY
Middle Name:E
Last Name:PENA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4191 BELLASOL CIR APT 511
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-7331
Mailing Address - Country:US
Mailing Address - Phone:857-540-1536
Mailing Address - Fax:
Practice Address - Street 1:12811 KENWOOD LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5667
Practice Address - Country:US
Practice Address - Phone:239-537-9646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH20185101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health