=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043789779
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE MARIE PENA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2018
-----------------------------------------------------
Last Update Date | 11/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2111 W. CONGRESS PKWY
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-201-7566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8630 FERRIS AVE UNIT 102
-----------------------------------------------------
City | MORTON GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60053-2833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-201-7566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------