Provider Demographics
NPI:1285310961
Name:PENA, KAREN GISSELLE
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:GISSELLE
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 1:3570 GAGE AVE APT D
Mailing Address - Street 2:
Mailing Address - City:BELL
Mailing Address - State:CA
Mailing Address - Zip Code:90201-1045
Mailing Address - Country:US
Mailing Address - Phone:323-519-5195
Mailing Address - Fax:
Practice Address - Street 1:290 S PROSPECT AVE STE A
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1523
Practice Address - Country:US
Practice Address - Phone:415-646-6223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician