Provider Demographics
NPI:1902567811
Name:PENA GERALDINO, IANKA
Entity type:Individual
Prefix:
First Name:IANKA
Middle Name:
Last Name:PENA GERALDINO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 S MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3758
Mailing Address - Country:US
Mailing Address - Phone:847-748-0341
Mailing Address - Fax:847-367-5997
Practice Address - Street 1:1113 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3758
Practice Address - Country:US
Practice Address - Phone:847-748-0341
Practice Address - Fax:847-367-5997
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208001056106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty