Provider Demographics
NPI:1528890381
Name:LASTRES PENA, RENE L
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:L
Last Name:LASTRES PENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8195 W 36TH AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-1847
Mailing Address - Country:US
Mailing Address - Phone:786-340-7597
Mailing Address - Fax:
Practice Address - Street 1:8195 W 36TH AVE APT 7
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-1847
Practice Address - Country:US
Practice Address - Phone:786-340-7597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-364556106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician