Healthcare Provider Details

I. General information

NPI: 1558472704
Provider Name (Legal Business Name): EDUARDO M PEREZ LCSW#16741
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4275 LEMON ST SUITE #205
RIVERSIDE CA
92501-3844
US

IV. Provider business mailing address

4000 ORANGE ST
RIVERSIDE CA
92501-3613
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-8541
  • Fax: 951-955-8542
Mailing address:
  • Phone: 951-955-4395
  • Fax: 951-955-2138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16471
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: