Basic Information
| Provider Information | |||||||||
| NPI: | 1265700884 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENA | ||||||||
| FirstName: | FERNANDO | ||||||||
| MiddleName: | JOSE | ||||||||
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| Credential: | CADC II | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16756 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972920756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035932129 | ||||||||
| FaxNumber: | 5032082596 | ||||||||
| Practice Location | |||||||||
| Address1: | 10209 SE DIVISION ST | ||||||||
| Address2: | BLDG D | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972661372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037160481 | ||||||||
| FaxNumber: | 5032082596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2011 | ||||||||
| LastUpdateDate: | 07/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 14-11-18 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.