Healthcare Provider Details

I. General information

NPI: 1639634876
Provider Name (Legal Business Name): CARMEN G PEREZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 S MICHIGAN AVE
CHICAGO IL
60604-4434
US

IV. Provider business mailing address

2605 W BERWYN AVE
CHICAGO IL
60625-3301
US

V. Phone/Fax

Practice location:
  • Phone: 888-660-4425
  • Fax:
Mailing address:
  • Phone: 401-339-8212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149-005477
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: