Provider Demographics
NPI:1255749214
Name:PEREZ, ERNESTINA (MA)
Entity type:Individual
Prefix:
First Name:ERNESTINA
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 N DEWITT PL APT 1005
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5771
Mailing Address - Country:US
Mailing Address - Phone:312-545-5090
Mailing Address - Fax:
Practice Address - Street 1:500 N MICHIGAN AVE STE 1042
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3783
Practice Address - Country:US
Practice Address - Phone:312-620-7551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL180011468101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health