Provider Demographics
NPI:1245574524
Name:PEREZ, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 FROST LN
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1306
Mailing Address - Country:US
Mailing Address - Phone:646-209-9949
Mailing Address - Fax:
Practice Address - Street 1:20 FROST LN
Practice Address - Street 2:
Practice Address - City:CORNWALL
Practice Address - State:NY
Practice Address - Zip Code:12518-1306
Practice Address - Country:US
Practice Address - Phone:646-209-9949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021754103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool