Provider Demographics
NPI:1780109702
Name:PEREZ, KATHERINE FEDEROWICZ
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:FEDEROWICZ
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 EDGARTOWN RD
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-5699
Mailing Address - Country:US
Mailing Address - Phone:508-693-7900
Mailing Address - Fax:
Practice Address - Street 1:111 EDGARTOWN RD
Practice Address - Street 2:
Practice Address - City:VINEYARD HAVEN
Practice Address - State:MA
Practice Address - Zip Code:02568-5699
Practice Address - Country:US
Practice Address - Phone:508-693-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-10
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126365106H00000X
MA101YM0800X
CA97404101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist