Provider Demographics
NPI:1891101408
Name:PEREZ, MARY CARMEN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CARMEN
Last Name:PEREZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 JACK CT
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-8716
Mailing Address - Country:US
Mailing Address - Phone:805-385-9420
Mailing Address - Fax:
Practice Address - Street 1:806 JACK CT
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-8716
Practice Address - Country:US
Practice Address - Phone:903-309-0702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1017501041C0700X
TX1054241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1891101408Medicaid