Healthcare Provider Details

I. General information

NPI: 1497004196
Provider Name (Legal Business Name): SANDRA PENA MA PSYCHOLOGY MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

566 S BRAND BLVD
SAN FERNANDO CA
91340
US

IV. Provider business mailing address

566 S BRAND BLVD
SAN FERNANDO CA
91340-4002
US

V. Phone/Fax

Practice location:
  • Phone: 661-478-1655
  • Fax:
Mailing address:
  • Phone: 661-478-1655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number107931
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number128977
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: