Provider Demographics
NPI:1578907481
Name:PERALTA, STEPHANIE M
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:PERALTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 ROUTE 304
Mailing Address - Street 2:
Mailing Address - City:BARDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:10954-2042
Mailing Address - Country:US
Mailing Address - Phone:845-507-0477
Mailing Address - Fax:
Practice Address - Street 1:175 ROUTE 304
Practice Address - Street 2:
Practice Address - City:BARDONIA
Practice Address - State:NY
Practice Address - Zip Code:10954-2042
Practice Address - Country:US
Practice Address - Phone:845-507-0477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024520225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist