Provider Demographics
NPI:1518168475
Name:PEREZ, MYRNA (CDS)
Entity Type:Individual
Prefix:MRS
First Name:MYRNA
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:CDS
Other - Prefix:MISS
Other - First Name:MYRNA
Other - Middle Name:
Other - Last Name:FELICIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CDS
Mailing Address - Street 1:3430 W PALMER ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3518
Mailing Address - Country:US
Mailing Address - Phone:773-550-7628
Mailing Address - Fax:773-394-0623
Practice Address - Street 1:3430 W PALMER ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-3518
Practice Address - Country:US
Practice Address - Phone:773-550-7628
Practice Address - Fax:773-394-0623
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILMF40761102P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist