Provider Demographics
NPI:1407295140
Name:PEREZ, GINELLY (MED)
Entity Type:Individual
Prefix:
First Name:GINELLY
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W ESTES AVE
Mailing Address - Street 2:3W
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-5462
Mailing Address - Country:US
Mailing Address - Phone:773-764-0289
Mailing Address - Fax:
Practice Address - Street 1:1301 W ESTES AVE
Practice Address - Street 2:3W
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-5462
Practice Address - Country:US
Practice Address - Phone:773-764-0289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-16
Last Update Date:2013-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist