Provider Demographics
NPI:1184601544
Name:PEROTTI, LAURENCE PETER (PHD)
Entity type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:PETER
Last Name:PEROTTI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4006 BENTWAY ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-1705
Mailing Address - Country:US
Mailing Address - Phone:210-310-8864
Mailing Address - Fax:
Practice Address - Street 1:BROOKE ARMY MEDICAL CENTER
Practice Address - Street 2:3551 ROGER BROOKE DR.
Practice Address - City:FT. SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234
Practice Address - Country:US
Practice Address - Phone:210-539-9567
Practice Address - Fax:210-539-6467
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-2336103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000000G497OtherBLUE CROSS BLUE SHIELD PR