Healthcare Provider Details

I. General information

NPI: 1912731126
Provider Name (Legal Business Name): KAYLA PENA LMSW, CSW INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2024
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 N STEPHANIE ST STE 21
HENDERSON NV
89014-8771
US

IV. Provider business mailing address

375 N STEPHANIE ST STE 21
HENDERSON NV
89014-8771
US

V. Phone/Fax

Practice location:
  • Phone: 702-799-9710
  • Fax: 702-799-9712
Mailing address:
  • Phone: 702-799-9710
  • Fax: 702-799-9712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8491-M
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: