Healthcare Provider Details

I. General information

NPI: 1184452658
Provider Name (Legal Business Name): ELLIOTTNELL PEREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 SADIE MAE DR
LEXINGTON NC
27295-7717
US

IV. Provider business mailing address

222 SADIE MAE DR
LEXINGTON NC
27295-7717
US

V. Phone/Fax

Practice location:
  • Phone: 203-993-2169
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810008991
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: