Healthcare Provider Details

I. General information

NPI: 1235082470
Provider Name (Legal Business Name): GLORIA PEREZ NEVAREZ SUDCC 17223
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2026
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1477 LINCOLN AVE
SAN RAFAEL CA
94901-2028
US

IV. Provider business mailing address

431 NORTH ST # B
HEALDSBURG CA
95448-4211
US

V. Phone/Fax

Practice location:
  • Phone: 415-459-2395
  • Fax:
Mailing address:
  • Phone: 415-459-2395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17223
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: