Provider Demographics
NPI:1649200080
Name:PEROVICH, GEORGE MICHAEL (EDD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:MICHAEL
Last Name:PEROVICH
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 S CEDAR CREST BLVD
Mailing Address - Street 2:SUITE 302A
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6205
Mailing Address - Country:US
Mailing Address - Phone:610-437-1431
Mailing Address - Fax:610-437-9150
Practice Address - Street 1:1251 S CEDAR CREST BLVD
Practice Address - Street 2:SUITE 302A
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6205
Practice Address - Country:US
Practice Address - Phone:610-437-1431
Practice Address - Fax:610-437-9150
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS0034647-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA402654OtherHIGHMARK
PA0041439000OtherIBC PERSONAL CHOICE
PA02690300OtherCAPITAL BLUE CROSS
PA02690300OtherCAPITAL BLUE CROSS