Provider Demographics
NPI:1720640394
Name:PEREZ, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9150 WATERMAN RD APT 116
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-5079
Mailing Address - Country:US
Mailing Address - Phone:916-886-6255
Mailing Address - Fax:
Practice Address - Street 1:9150 WATERMAN RD APT 116
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-5079
Practice Address - Country:US
Practice Address - Phone:916-886-6255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12345OtherINTERCOASTCOLLEGE