Provider Demographics
NPI:1215818398
Name:PENA, GENESIS
Entity type:Individual
Prefix:
First Name:GENESIS
Middle Name:
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 1:302 EUSTIS ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-3800
Mailing Address - Country:US
Mailing Address - Phone:857-339-3099
Mailing Address - Fax:
Practice Address - Street 1:302 EUSTIS ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-3800
Practice Address - Country:US
Practice Address - Phone:857-339-3099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator