Provider Demographics
NPI:1457102113
Name:PEROVICH, MICHAEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:PEROVICH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 GLENLIVET DR STE A18
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18106-3112
Mailing Address - Country:US
Mailing Address - Phone:484-358-1736
Mailing Address - Fax:
Practice Address - Street 1:1150 GLENLIVET DR STE A18
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18106-3112
Practice Address - Country:US
Practice Address - Phone:484-358-1736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-005177-L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist