Provider Demographics
NPI:1639919574
Name:PEREZ, SHAKARA SIMONE (MSED)
Entity type:Individual
Prefix:MS
First Name:SHAKARA
Middle Name:SIMONE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-2943
Mailing Address - Country:US
Mailing Address - Phone:646-233-8350
Mailing Address - Fax:
Practice Address - Street 1:131 W 2ND ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2943
Practice Address - Country:US
Practice Address - Phone:646-233-8350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1794100241174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist