Provider Demographics
NPI:1689809600
Name:KAPERONIS, MIRTA I (LCSW)
Entity Type:Individual
Prefix:
First Name:MIRTA
Middle Name:I
Last Name:KAPERONIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 ACOMA BLVD S
Mailing Address - Street 2:SUITE 101-103
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5957
Mailing Address - Country:US
Mailing Address - Phone:928-680-0604
Mailing Address - Fax:928-680-0605
Practice Address - Street 1:30 ACOMA BLVD S
Practice Address - Street 2:SUITE101-103
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5957
Practice Address - Country:US
Practice Address - Phone:928-680-0604
Practice Address - Fax:928-680-0605
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-10019101Y00000X
AZLASAC-13100101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLCSW-10019OtherSTATE LICENSE
AZLASAC-13100OtherSTATE LICENSE