Basic Information
| Provider Information | |||||||||
| NPI: | 1003472440 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINO PENA | ||||||||
| FirstName: | TOMAS | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CDPT60922995 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 NW CHEHALIS AVE | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985322010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609480203 | ||||||||
| FaxNumber: | 3602626703 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 N MARKET BLVD STE C | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985322677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609480203 | ||||||||
| FaxNumber: | 3602626703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2019 | ||||||||
| LastUpdateDate: | 05/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1376696096 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.