Provider Demographics
NPI:1619344892
Name:PERUSQUIA, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:PERUSQUIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3580 WILSHIRE BLVD FL 8
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2505
Mailing Address - Country:US
Mailing Address - Phone:213-637-5000
Mailing Address - Fax:213-637-5001
Practice Address - Street 1:3580 WILSHIRE BLVD FL 8
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2505
Practice Address - Country:US
Practice Address - Phone:213-637-5000
Practice Address - Fax:213-637-5001
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF94418106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist