Basic Information
Provider Information | |||||||||
NPI: | 1104467893 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PENA | ||||||||
FirstName: | ALEXANDER | ||||||||
MiddleName: | MIGUEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 80 COMMERCIAL ST | ||||||||
Address2: |   | ||||||||
City: | HOLYOKE | ||||||||
State: | MA | ||||||||
PostalCode: | 010404704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4138460445 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 80 COMMERCIAL ST | ||||||||
Address2: |   | ||||||||
City: | HOLYOKE | ||||||||
State: | MA | ||||||||
PostalCode: | 010404704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4138460445 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2019 | ||||||||
LastUpdateDate: | 10/03/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
ID Information
ID | Type | State | Issuer | Description | 042622756 | 01 | MA | CCA | OTHER | 71756 | 01 | MA | TUFTS | OTHER | 997303 | 01 | MA | NETWORK HEALTH | OTHER | Y10086 | 01 | MA | MEDICARE | OTHER | 1134107113 | 01 | MA | MBHP | OTHER | 1134107113 | 01 | MA | FALLON | OTHER | 1134107113 | 01 | MA | BEACON | OTHER | 1134107113 | 01 | MA | NHP | OTHER | 1134107113 | 05 | MA |   | MEDICAID | 12529 | 01 | MA | HNE | OTHER |