Provider Demographics
NPI:1518018019
Name:PERNA, PHYLLIS ANN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:ANN
Last Name:PERNA
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 1:527 STEVENSON RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:NY
Mailing Address - Zip Code:12993-2219
Mailing Address - Country:US
Mailing Address - Phone:610-730-5613
Mailing Address - Fax:
Practice Address - Street 1:107 HAND AVENUE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NY
Practice Address - Zip Code:12932
Practice Address - Country:US
Practice Address - Phone:518-962-8884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018491-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001535699Medicaid