MEDICARE: STEPHANIE PENA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1053072462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE PENA

Provider Business Mailing Address
First Line	:	2550 N HOLLYWOOD WAY STE 102
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-5031
Country	:	US
Telephone Number	:	866-727-8274
Fax Number	:

Provider Business Practice Location Address
First Line	:	338 VIA VERA CRUZ # 130
Second Line	:
City	:	SAN MARCOS
State	:	CA
Zip	:	92078-2645
Country	:	US
Telephone Number	:	866-727-8274
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2022
Last Update Date	:	01/07/2022

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Directions to “ STEPHANIE PENA ” Practice Location

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