Provider Demographics
NPI:1609472497
Name:PENA, LESLIE (COTA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 OPUNTIA LN
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78541-1024
Mailing Address - Country:US
Mailing Address - Phone:956-534-3130
Mailing Address - Fax:
Practice Address - Street 1:800 S 16TH 1/2 ST
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-5263
Practice Address - Country:US
Practice Address - Phone:956-328-5424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216513224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX216513OtherTBOTE
TX443728OtherNBCOT