MEDICARE: DR. GRACE PENA PSYD, LMHC

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	MH 5773	FL

General Provider Information

NPI Number	:	1821051491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRACE PENA PSYD, LMHC

Provider Business Mailing Address
First Line	:	316 BRIMMING LAKE RD
Second Line	:
City	:	MINNEOLA
State	:	FL
Zip	:	34715-6000
Country	:	US
Telephone Number	:	407-209-7492
Fax Number	:	352-241-8372

Provider Business Practice Location Address
First Line	:	600 U.S. HWY 27 SUITE # 1
Second Line	:
City	:	MINNEOLA
State	:	FL
Zip	:	34715-6000
Country	:	US
Telephone Number	:	407-209-7492
Fax Number	:	352-241-8372

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

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	07/08/2007

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