Healthcare Provider Details

I. General information

NPI: 1396526760
Provider Name (Legal Business Name): ASTRID ELENA PENA PEREZ M.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2023
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 NW 107TH AVE STE 110
MIAMI FL
33172-3100
US

IV. Provider business mailing address

11605 NW 89TH ST APT 225
DORAL FL
33178-1786
US

V. Phone/Fax

Practice location:
  • Phone: 305-964-5426
  • Fax:
Mailing address:
  • Phone: 786-294-3591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH24783
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: