Provider Demographics
NPI:1205402476
Name:PEREZ, KRISTEN M (COTA/L)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:PEREZ
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6015 CATALINA DR UNIT 713
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-9514
Mailing Address - Country:US
Mailing Address - Phone:843-582-8014
Mailing Address - Fax:
Practice Address - Street 1:491 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-8082
Practice Address - Country:US
Practice Address - Phone:843-399-6454
Practice Address - Fax:843-399-6463
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5073224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant