Basic Information
| Provider Information | |||||||||
| NPI: | 1679229041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENA | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PICHARDO | ||||||||
| OtherFirstName: | SANDRA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7649 VELVET MIST ST | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891313651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5627130486 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2980 S RAINBOW BLVD # 210D | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891466531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026737462 | ||||||||
| FaxNumber: | 7024428900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2022 | ||||||||
| LastUpdateDate: | 02/24/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 9682-M | NV | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.