Provider Demographics
NPI:1740668714
Name:PEREZ, IDA LISSETE (MSED SWD)
Entity type:Individual
Prefix:MRS
First Name:IDA
Middle Name:LISSETE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:MSED SWD
Other - Prefix:
Other - First Name:IDA
Other - Middle Name:LISSETE
Other - Last Name:CREQUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:34 STEPHENS RD
Mailing Address - Street 2:
Mailing Address - City:TAPPAN
Mailing Address - State:NY
Mailing Address - Zip Code:10983-2309
Mailing Address - Country:US
Mailing Address - Phone:646-942-4941
Mailing Address - Fax:
Practice Address - Street 1:34 STEPHENS RD
Practice Address - Street 2:
Practice Address - City:TAPPAN
Practice Address - State:NY
Practice Address - Zip Code:10983-2309
Practice Address - Country:US
Practice Address - Phone:646-942-4941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist