Provider Demographics
NPI:1497019558
Name:PEREZ, MARK ANTHONY
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
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 1:335 E LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-4826
Mailing Address - Country:US
Mailing Address - Phone:831-728-6445
Mailing Address - Fax:831-761-6011
Practice Address - Street 1:335 E LAKE AVE
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-4826
Practice Address - Country:US
Practice Address - Phone:831-728-6445
Practice Address - Fax:831-761-6011
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA912611041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical