Provider Demographics
NPI:1679948699
Name:PENA, ROSE MARIE
Entity type:Individual
Prefix:
First Name:ROSE MARIE
Middle Name:
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 1:580 ELLIS RD S
Mailing Address - Street 2:SUITE 118
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-3582
Mailing Address - Country:US
Mailing Address - Phone:904-423-0017
Mailing Address - Fax:904-683-8169
Practice Address - Street 1:580 ELLIS RD S
Practice Address - Street 2:SUITE 118
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-3582
Practice Address - Country:US
Practice Address - Phone:904-423-0017
Practice Address - Fax:904-683-8169
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT2414106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist