Provider Demographics
NPI:1962015040
Name:PEREA, CHRISTOPHER L
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:L
Last Name:PEREA
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 1:1072 AVENIDA LAS VISTAS NW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-8381
Mailing Address - Country:US
Mailing Address - Phone:505-702-5359
Mailing Address - Fax:
Practice Address - Street 1:1072 AVENIDA LAS VISTAS NW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-8381
Practice Address - Country:US
Practice Address - Phone:505-702-5359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician