Healthcare Provider Details

I. General information

NPI: 1295922870
Provider Name (Legal Business Name): JUAN JOSE PENA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W VICTORIA ST
GARDENA CA
90248
US

IV. Provider business mailing address

108 W VICTORIA ST
GARDENA CA
90248-3523
US

V. Phone/Fax

Practice location:
  • Phone: 310-715-2020
  • Fax:
Mailing address:
  • Phone: 310-715-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 59897
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: