Provider Demographics
NPI:1194303156
Name:DE PENA, ALYSSA ROSE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ROSE
Last Name:DE 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 1:22 AMALFI WAY
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34758-3403
Mailing Address - Country:US
Mailing Address - Phone:407-729-5532
Mailing Address - Fax:
Practice Address - Street 1:22 AMALFI WAY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34758
Practice Address - Country:US
Practice Address - Phone:407-995-6106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician