Healthcare Provider Details

I. General information

NPI: 1992286520
Provider Name (Legal Business Name): MR. ALEX KENNETH PENA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 BISSO LN
CONCORD CA
94520-4832
US

IV. Provider business mailing address

390 40TH ST
OAKLAND CA
94609-2633
US

V. Phone/Fax

Practice location:
  • Phone: 925-608-6775
  • Fax:
Mailing address:
  • Phone: 510-613-0330
  • Fax: 510-569-4589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number92604
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number125769
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: