Provider Demographics
NPI:1235753377
Name:PENA, MARCOS (LCSW, LADAC)
Entity type:Individual
Prefix:
First Name:MARCOS
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:LCSW, LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6061 FENDER HILL ST
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9483
Mailing Address - Country:US
Mailing Address - Phone:915-248-7067
Mailing Address - Fax:
Practice Address - Street 1:2601 E YANDELL DR STE 118
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-3743
Practice Address - Country:US
Practice Address - Phone:915-260-8113
Practice Address - Fax:833-428-3821
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2023-0281101YA0400X
NMSWB-2023-05791041C0700X
TX1033621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)