Healthcare Provider Details

I. General information

NPI: 1518457365
Provider Name (Legal Business Name): TYLER PENA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10537 S ROBERTS RD
PALOS HILLS IL
60465-1933
US

IV. Provider business mailing address

10537 S ROBERTS RD
PALOS HILLS IL
60465-1933
US

V. Phone/Fax

Practice location:
  • Phone: 708-974-2300
  • Fax: 708-974-2498
Mailing address:
  • Phone: 708-974-2300
  • Fax: 708-974-2498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180014127
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: