Provider Demographics
NPI:1548855323
Name:PENA, RAFAEL A JR (LCADC)
Entity type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:A
Last Name:PENA
Suffix:JR
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 TIFFANY BLVD APT 228
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-2470
Mailing Address - Country:US
Mailing Address - Phone:201-658-5044
Mailing Address - Fax:
Practice Address - Street 1:136 TIFFANY BLVD APT 228
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-2470
Practice Address - Country:US
Practice Address - Phone:201-658-5044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00327800101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty