Provider Demographics
NPI:1790372134
Name:PEREZ, CYNTHIA IVONNE
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:IVONNE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:NIXON
Mailing Address - State:TX
Mailing Address - Zip Code:78140-2923
Mailing Address - Country:US
Mailing Address - Phone:210-606-1603
Mailing Address - Fax:
Practice Address - Street 1:113 S ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:NIXON
Practice Address - State:TX
Practice Address - Zip Code:78140-2923
Practice Address - Country:US
Practice Address - Phone:210-606-1603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT134296225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty