Provider Demographics
NPI:1275696320
Name:PERUO, COLLEEN M (CP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:PERUO
Suffix:
Gender:F
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-4220
Mailing Address - Country:US
Mailing Address - Phone:973-779-1107
Mailing Address - Fax:973-779-4555
Practice Address - Street 1:1314 BROAD ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-4220
Practice Address - Country:US
Practice Address - Phone:973-779-1107
Practice Address - Fax:973-779-4555
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSI3181103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6260306Medicaid
NJ6260306Medicaid