Provider Demographics
NPI:1851760680
Name:PERALTA, KENIA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KENIA
Middle Name:
Last Name:PERALTA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HIGHFIELD LN
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1928
Mailing Address - Country:US
Mailing Address - Phone:973-542-8065
Mailing Address - Fax:
Practice Address - Street 1:242 WASHINGTON AVE
Practice Address - Street 2:LOWER LEVEL J
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-3934
Practice Address - Country:US
Practice Address - Phone:973-563-8837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00545900235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist