Provider Demographics
NPI:1326395831
Name:PENA, DIANE (MA, MSED, COMS)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:MA, MSED, COMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4830 40TH ST
Mailing Address - Street 2:APT. 1G
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-4146
Mailing Address - Country:US
Mailing Address - Phone:917-698-3771
Mailing Address - Fax:
Practice Address - Street 1:4830 40TH ST
Practice Address - Street 2:APT. 1G
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-4146
Practice Address - Country:US
Practice Address - Phone:917-698-3771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY616526051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist