Provider Demographics
NPI:1083311252
Name:PERO, TATIANA (PTA)
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:PERO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 COZUMEL
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-4450
Mailing Address - Country:US
Mailing Address - Phone:201-874-7611
Mailing Address - Fax:
Practice Address - Street 1:170 COZUMEL
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-4450
Practice Address - Country:US
Practice Address - Phone:201-874-7611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51618225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant