Provider Demographics
NPI:1912553397
Name:PEREZ-MAZARA, EDDY
Entity Type:Individual
Prefix:
First Name:EDDY
Middle Name:
Last Name:PEREZ-MAZARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 ROBIN ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-1995
Mailing Address - Country:US
Mailing Address - Phone:702-539-2199
Mailing Address - Fax:
Practice Address - Street 1:1432 ROBIN ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-1995
Practice Address - Country:US
Practice Address - Phone:702-539-2199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2104099769106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician