Provider Demographics
NPI:1003352253
Name:PEREZ, MYRTA
Entity Type:Individual
Prefix:
First Name:MYRTA
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-3101
Mailing Address - Country:US
Mailing Address - Phone:347-726-6828
Mailing Address - Fax:212-726-6808
Practice Address - Street 1:429 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-3101
Practice Address - Country:US
Practice Address - Phone:347-726-6828
Practice Address - Fax:212-726-6808
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0696211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical