Provider Demographics
NPI:1083165542
Name:PEREZ, JOSEPHINE M M
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:M M
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOSEPHINE
Other - Middle Name:M R
Other - Last Name:MESA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12848 BROOKS LN
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-2007
Mailing Address - Country:US
Mailing Address - Phone:310-715-2020
Mailing Address - Fax:
Practice Address - Street 1:108 W VICTORIA ST
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-3523
Practice Address - Country:US
Practice Address - Phone:310-715-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist