Provider Demographics
NPI:1295241974
Name:PEREZ-RODRIGUEZ, EVITA (LMSW)
Entity type:Individual
Prefix:
First Name:EVITA
Middle Name:
Last Name:PEREZ-RODRIGUEZ
Suffix:
Gender:U
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:DOBBS FERRY
Mailing Address - State:NY
Mailing Address - Zip Code:10522-2835
Mailing Address - Country:US
Mailing Address - Phone:646-988-7779
Mailing Address - Fax:
Practice Address - Street 1:900 INTERVALE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-4240
Practice Address - Country:US
Practice Address - Phone:718-732-7168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000850104100000X
NY101470104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY163W00000XMedicaid