Provider Demographics
NPI:1003028341
Name:PEREZ, STEPHANIE ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ANN
Last Name:PEREZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 PORT WATSON ST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-3027
Mailing Address - Country:US
Mailing Address - Phone:607-753-6511
Mailing Address - Fax:607-753-1648
Practice Address - Street 1:73 PORT WATSON ST
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-3027
Practice Address - Country:US
Practice Address - Phone:607-753-6511
Practice Address - Fax:607-753-1648
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012191103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY246-683OtherVALUE OPTIONS NUMBER
NYS12191-3OtherWCB AUTH #
NY688-5837OtherVALUE OPTIONS GHI PIN NUM
NY040728-000-060OtherFIDELIS
NYS12191-3OtherWCB AUTH #
NYS23468Medicare UPIN