Provider Demographics
NPI:1538650510
Name:PEREZ, GWENDOLYN (MS)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 STATE ST STE 7-276
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-3138
Mailing Address - Country:US
Mailing Address - Phone:661-425-7066
Mailing Address - Fax:805-299-4505
Practice Address - Street 1:23030 LYONS AVE STE 200
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2754
Practice Address - Country:US
Practice Address - Phone:661-425-7066
Practice Address - Fax:805-299-4505
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-29360103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1-18-29360OtherBACB