Provider Demographics
NPI:1710643184
Name:PERALTA, JOHN RAFAEL
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RAFAEL
Last Name:PERALTA
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 1:8 CHASE ST APT 17
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-4326
Mailing Address - Country:US
Mailing Address - Phone:617-777-5541
Mailing Address - Fax:
Practice Address - Street 1:8 CHASE ST APT 17
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-4326
Practice Address - Country:US
Practice Address - Phone:617-777-5541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician