Provider Demographics
NPI:1265646772
Name:PEREZ, LISSETTE
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
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:PO BOX 11447
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00922-1447
Mailing Address - Country:US
Mailing Address - Phone:787-612-4832
Mailing Address - Fax:
Practice Address - Street 1:474 CALLE DE DIEGO
Practice Address - Street 2:APT 7B6
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00923-3101
Practice Address - Country:US
Practice Address - Phone:787-612-4832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2424103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist