Provider Demographics
NPI:1659491876
Name:PEREZ, ROSA E (BA)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:E
Last Name:PEREZ
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17351 BURBANK BLVD
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1733
Mailing Address - Country:US
Mailing Address - Phone:818-309-0327
Mailing Address - Fax:
Practice Address - Street 1:11303 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6003
Practice Address - Country:US
Practice Address - Phone:310-482-6619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSIX946Medicaid