Provider Demographics
NPI:1326079088
Name:PEREZ - LANE, AWILDA (PSYD)
Entity Type:Individual
Prefix:
First Name:AWILDA
Middle Name:
Last Name:PEREZ - LANE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 MAIN ST APT 126
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-5743
Mailing Address - Country:US
Mailing Address - Phone:201-315-8140
Mailing Address - Fax:
Practice Address - Street 1:156 W 56TH ST STE 1804
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3878
Practice Address - Country:US
Practice Address - Phone:212-851-8100
Practice Address - Fax:212-537-0102
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI100429700103TA0700X
NJ013880103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ013880OtherLICENSE