MEDICARE: ASTRID ELENA PENA PEREZ M.S

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	101YM0800X	Mental Health Counselor	IMH24783	FL

General Provider Information

NPI Number	:	1396526760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASTRID ELENA PENA PEREZ M.S

Provider Business Mailing Address
First Line	:	11605 NW 89TH ST APT 225
Second Line	:
City	:	DORAL
State	:	FL
Zip	:	33178-1786
Country	:	US
Telephone Number	:	786-294-3591
Fax Number	:

Provider Business Practice Location Address
First Line	:	790 NW 107TH AVE STE 110
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33172-3100
Country	:	US
Telephone Number	:	305-964-5426
Fax Number	:

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

Provider Enumeration Date	:	10/11/2023
Last Update Date	:	10/23/2023

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