Provider Demographics
NPI:1306360524
Name:PEREZ, JOHNATHAN WINSTON
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:WINSTON
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 1:109 OAK ST STE 103
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02464-1493
Mailing Address - Country:US
Mailing Address - Phone:617-658-5611
Mailing Address - Fax:
Practice Address - Street 1:109 OAK ST STE 103
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02464-1493
Practice Address - Country:US
Practice Address - Phone:617-658-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2093103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst