Provider Demographics
NPI:1538662432
Name:MV PERERA LICENSED CLINICAL SOCIAL WORKER, INC.
Entity Type:Organization
Organization Name:MV PERERA LICENSED CLINICAL SOCIAL WORKER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MANOJ
Authorized Official - Middle Name:V
Authorized Official - Last Name:PERERA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:916-947-5279
Mailing Address - Street 1:8475 BLUE MAIDEN CT
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-3897
Mailing Address - Country:US
Mailing Address - Phone:916-947-5279
Mailing Address - Fax:530-852-0944
Practice Address - Street 1:3332 HEIGHTS DR STE 235
Practice Address - Street 2:
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-7774
Practice Address - Country:US
Practice Address - Phone:916-947-5279
Practice Address - Fax:530-852-0944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA242601041C0700X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty