MEDICARE: PATRICIA PENA THERAPY LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1457983868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATRICIA PENA THERAPY LLC

Provider Business Mailing Address
First Line	:	1734 W RASCHER AVE FL 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1118
Country	:	US
Telephone Number	:	773-807-5101
Fax Number	:

Provider Business Practice Location Address
First Line	:	3705 N ELSTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-4309
Country	:	US
Telephone Number	:	507-556-7289
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PSYCHOTHERAPIST
Name	:	PATRICIA PENA
Credential	:	LMFT
Telephone Number	:	773-807-5101

Provider Enumeration Date	:	02/04/2020
Last Update Date	:	02/04/2020

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