Healthcare Provider Details

I. General information

NPI: 1518566868
Provider Name (Legal Business Name): ILZA STEPHANY PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7223 LEE DEFOREST DR
COLUMBIA MD
21046-3236
US

IV. Provider business mailing address

6916 EMIL AVE
BELL GARDENS CA
90201-3214
US

V. Phone/Fax

Practice location:
  • Phone: 813-371-7147
  • Fax:
Mailing address:
  • Phone: 562-774-6157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number250126454
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: