Basic Information
| Provider Information | |||||||||
| NPI: | 1013320001 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENA | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | ALEJANDRO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1690 W SHAW AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937113519 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1690 W SHAW AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937113519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553431057 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2014 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 112004 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.