Provider Demographics
NPI:1003220450
Name:CESPEDES PEREZ, DUARTE (SAC-IT)
Entity Type:Individual
Prefix:
First Name:DUARTE
Middle Name:
Last Name:CESPEDES PEREZ
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W9850 AIRPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-9998
Mailing Address - Country:US
Mailing Address - Phone:715-284-9851
Mailing Address - Fax:
Practice Address - Street 1:W9850 AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-9998
Practice Address - Country:US
Practice Address - Phone:715-284-9851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17175101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)