=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649926445
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FATIMA COLOME PENA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2022
-----------------------------------------------------
Last Update Date | 03/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9415 SW 72ND ST STE 131
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33173-5492
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-662-6448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15679 SW 73RD CIRCLE TER APT 36
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33193-1843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-631-0814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------