Provider Demographics
NPI:1104036508
Name:PEREZ, JAVIER EDUARDO (LMSW)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:EDUARDO
Last Name:PEREZ
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 892
Mailing Address - Street 2:
Mailing Address - City:AU SABLE FORKS
Mailing Address - State:NY
Mailing Address - Zip Code:12912-0892
Mailing Address - Country:US
Mailing Address - Phone:518-647-5313
Mailing Address - Fax:
Practice Address - Street 1:ROUTE 73
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NY
Practice Address - Zip Code:12942
Practice Address - Country:US
Practice Address - Phone:518-576-4557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066951-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health