Healthcare Provider Details

I. General information

NPI: 1720631096
Provider Name (Legal Business Name): MIREYA PENA LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIREYA GONZALEZ

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11175 SAN PABLO AVE
EL CERRITO CA
94530-2157
US

IV. Provider business mailing address

PO BOX 6292
ALBANY CA
94706-0292
US

V. Phone/Fax

Practice location:
  • Phone: 415-444-5580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number116925
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: