Provider Demographics
NPI:1689262438
Name:PENA, KEERSHE LEE
Entity type:Individual
Prefix:
First Name:KEERSHE
Middle Name:LEE
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 1:3424 KOSSUTH AVE
Mailing Address - Street 2:4B BEHAVIOR HEALTH OUTPATIENT CLINIC
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2105
Mailing Address - Country:US
Mailing Address - Phone:929-445-0334
Mailing Address - Fax:
Practice Address - Street 1:3424 KOSSUTH AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2410
Practice Address - Country:US
Practice Address - Phone:718-519-3440
Practice Address - Fax:718-519-3781
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY097808-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical