MEDICARE: ALEXIS PENA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		IN

General Provider Information

NPI Number	:	1417885542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXIS PENA

Provider Business Mailing Address
First Line	:	5601 COVENTRY LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7145
Country	:	US
Telephone Number	:	260-459-6040
Fax Number	:

Provider Business Practice Location Address
First Line	:	5601 COVENTRY LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7145
Country	:	US
Telephone Number	:	260-459-6040
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2026
Last Update Date	:	05/11/2026

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Directions to “ ALEXIS PENA ” Practice Location

Language	Start Address	Practice Location

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