Provider Demographics
NPI:1578199824
Name:PEREZ, GABE E (COTA)
Entity Type:Individual
Prefix:
First Name:GABE
Middle Name:E
Last Name:PEREZ
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 CHURCH ROCK ST
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4572
Mailing Address - Country:US
Mailing Address - Phone:505-722-2261
Mailing Address - Fax:
Practice Address - Street 1:3720 CHURCH ROCK ST
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4572
Practice Address - Country:US
Practice Address - Phone:505-722-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOTA2834224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant