Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 1376696096 | WA |
NPI | 1003472440 |
---|---|
Provider Name | Tomas D Mino Pena |
First Address | Chehalis, WA 98532-2010 |
Second Address | Chehalis, WA 98532-2677 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2019 |
Last Update Date | 24/05/2019 |