Healthcare Provider Details

I. General information

NPI: 1619494192
Provider Name (Legal Business Name): MARIELA PENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 08/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 CHERRY RIDGE ST
SAN ANTONIO TX
78230-4823
US

IV. Provider business mailing address

10102 INGRAM RD APT 8201
SAN ANTONIO TX
78245-1193
US

V. Phone/Fax

Practice location:
  • Phone: 210-692-0222
  • Fax:
Mailing address:
  • Phone: 956-319-5558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number38944
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: