MEDICARE: GINO FRANCESCO PENA M.S.ED

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	103K00000X	Behavior Analyst	701656131	NY

General Provider Information

NPI Number	:	1972935138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINO FRANCESCO PENA M.S.ED

Provider Business Mailing Address
First Line	:	6 MELISSA DR
Second Line	:
City	:	LAKE GROVE
State	:	NY
Zip	:	11755-2605
Country	:	US
Telephone Number	:	631-525-3415
Fax Number	:

Provider Business Practice Location Address
First Line	:	6 MELISSA DR
Second Line	:
City	:	LAKE GROVE
State	:	NY
Zip	:	11755-2605
Country	:	US
Telephone Number	:	631-525-3415
Fax Number	:

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

Provider Enumeration Date	:	07/30/2013
Last Update Date	:	07/30/2013

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