Provider Demographics
NPI:1679085377
Name:PENA, NIDIA (MSW)
Entity type:Individual
Prefix:
First Name:NIDIA
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12070 TELEGRAPH RD STE 207
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-8213
Mailing Address - Country:US
Mailing Address - Phone:562-777-7500
Mailing Address - Fax:562-777-7510
Practice Address - Street 1:12070 TELEGRAPH RD STE 207
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-8213
Practice Address - Country:US
Practice Address - Phone:562-777-7500
Practice Address - Fax:562-777-7510
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225C00000X
CA1268531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor