Healthcare Provider Details

I. General information

NPI: 1730617572
Provider Name (Legal Business Name): STACEY PENA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PRENTIS ST
SUFFOLK VA
23434-4433
US

IV. Provider business mailing address

201 PRENTIS ST
SUFFOLK VA
23434-4433
US

V. Phone/Fax

Practice location:
  • Phone: 757-725-4405
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904020506
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: