Provider Demographics
NPI:1609344811
Name:PEREZ, SOPHIA KALYNN (CMA)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:KALYNN
Last Name:PEREZ
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:SOPHIA
Other - Middle Name:KALYNN
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CMA
Mailing Address - Street 1:201 HIGHLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:BUENA
Mailing Address - State:WA
Mailing Address - Zip Code:98921
Mailing Address - Country:US
Mailing Address - Phone:509-865-6705
Mailing Address - Fax:509-865-5011
Practice Address - Street 1:201 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:ZILLAH
Practice Address - State:WA
Practice Address - Zip Code:98953-9716
Practice Address - Country:US
Practice Address - Phone:509-865-6705
Practice Address - Fax:509-865-2011
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPEREZSK075D7101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-0755984Medicaid