MEDICARE: EVANGELINA PEREZ LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	101YM0800X	Mental Health Counselor	107983	CA

General Provider Information

NPI Number	:	1083801971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVANGELINA PEREZ LCSW

Provider Business Mailing Address
First Line	:	411 N INDIAN HILL BLVD
Second Line	:
City	:	CLAREMONT
State	:	CA
Zip	:	91711-4614
Country	:	US
Telephone Number	:	626-214-8384
Fax Number	:

Provider Business Practice Location Address
First Line	:	411 N INDIAN HILL BLVD
Second Line	:
City	:	CLAREMONT
State	:	CA
Zip	:	91711-4614
Country	:	US
Telephone Number	:	626-214-8384
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2007
Last Update Date	:	06/06/2024

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