Provider Demographics
NPI:1811575293
Name:PEREZ, CAROLYN (NA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:NA
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13210 14TH ST
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-4369
Mailing Address - Country:US
Mailing Address - Phone:909-696-1308
Mailing Address - Fax:
Practice Address - Street 1:1801 EXCISE AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-8554
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician