Provider Demographics
NPI:1548899982
Name:PENA MORA, WENDY B (ACTIVITIES COORDINAT)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:B
Last Name:PENA MORA
Suffix:
Gender:F
Credentials:ACTIVITIES COORDINAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 S 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3013
Mailing Address - Country:US
Mailing Address - Phone:626-214-1480
Mailing Address - Fax:
Practice Address - Street 1:535 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3013
Practice Address - Country:US
Practice Address - Phone:626-214-1480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist