Provider Demographics
NPI:1144574773
Name:PERALTA, IDONELBA A
Entity Type:Individual
Prefix:MS
First Name:IDONELBA
Middle Name:A
Last Name:PERALTA
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 1:50 REDFIELD ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-3630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 REDFIELD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3630
Practice Address - Country:US
Practice Address - Phone:857-217-3755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health