Provider Demographics
NPI:1225800758
Name:PEREZ, AUDREY INES
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:INES
Last Name:PEREZ
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 1:96 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8127
Mailing Address - Country:US
Mailing Address - Phone:323-314-3633
Mailing Address - Fax:
Practice Address - Street 1:5029 LA MART DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0605
Practice Address - Country:US
Practice Address - Phone:714-587-4543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA137173101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health