Healthcare Provider Details

I. General information

NPI: 1538662432
Provider Name (Legal Business Name): MV PERERA LICENSED CLINICAL SOCIAL WORKER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 03/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3332 HEIGHTS DR STE 235
CAMERON PARK CA
95682-7774
US

IV. Provider business mailing address

8475 BLUE MAIDEN CT
ELK GROVE CA
95624-3897
US

V. Phone/Fax

Practice location:
  • Phone: 916-947-5279
  • Fax: 530-852-0944
Mailing address:
  • Phone: 916-947-5279
  • Fax: 530-852-0944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24260
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MANOJ V PERERA
Title or Position: CEO
Credential: LCSW
Phone: 916-947-5279