Provider Demographics
NPI:1891250684
Name:PEREGRINA, IRENE MONIQUE
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:MONIQUE
Last Name:PEREGRINA
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 1:618 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-4005
Mailing Address - Country:US
Mailing Address - Phone:626-495-5001
Mailing Address - Fax:
Practice Address - Street 1:618 N 5TH ST
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-4005
Practice Address - Country:US
Practice Address - Phone:626-495-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician