Provider Demographics
NPI:1821596735
Name:PEREZ, ELIZABETH ANN
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
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 1:1915 S 58TH CT
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2119
Mailing Address - Country:US
Mailing Address - Phone:708-890-2590
Mailing Address - Fax:
Practice Address - Street 1:8311 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2529
Practice Address - Country:US
Practice Address - Phone:708-771-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid