=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861919185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATOSHA A. PENA, LPC, LCC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2017
-----------------------------------------------------
Last Update Date | 08/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7807 AIRLINE DR STE 210
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70003-6437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-717-8592
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2115 ILLINOIS AVE
-----------------------------------------------------
City | KENNER
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70062-5920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-717-8592
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NATOSHA PENA
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 504-717-8592
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 5056
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------