Healthcare Provider Details

I. General information

NPI: 1609433382
Provider Name (Legal Business Name): JUANA PEREZ REV.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 MONROE ST FL 2
PASSAIC NJ
07055-5207
US

IV. Provider business mailing address

307 MONROE ST FL 2
PASSAIC NJ
07055-5207
US

V. Phone/Fax

Practice location:
  • Phone: 973-510-5465
  • Fax:
Mailing address:
  • Phone: 973-510-5465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberTTC-IIII-07-30-2013
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: