Provider Demographics
NPI:1114764297
Name:PENA, GISSEL NOEMI
Entity type:Individual
Prefix:
First Name:GISSEL
Middle Name:NOEMI
Last Name:PENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 W 82ND PL
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459-1835
Mailing Address - Country:US
Mailing Address - Phone:773-415-6519
Mailing Address - Fax:
Practice Address - Street 1:6101 W 82ND PL
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-1835
Practice Address - Country:US
Practice Address - Phone:773-415-6519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.007852235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist