Healthcare Provider Details

I. General information

NPI: 1679085377
Provider Name (Legal Business Name): NIDIA PENA MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12070 TELEGRAPH RD STE 207
SANTA FE SPRINGS CA
90670-8213
US

IV. Provider business mailing address

12070 TELEGRAPH RD STE 207
SANTA FE SPRINGS CA
90670-8213
US

V. Phone/Fax

Practice location:
  • Phone: 562-777-7500
  • Fax: 562-777-7510
Mailing address:
  • Phone: 562-777-7500
  • Fax: 562-777-7510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126853
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: