Provider Demographics
NPI:1164396164
Name:PEREIRA, THIAGO PRUNER
Entity type:Individual
Prefix:
First Name:THIAGO
Middle Name:PRUNER
Last Name:PEREIRA
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 1:112 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1148
Mailing Address - Country:US
Mailing Address - Phone:781-592-5691
Mailing Address - Fax:
Practice Address - Street 1:112 MARKET ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1148
Practice Address - Country:US
Practice Address - Phone:781-592-5691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-02
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor