Healthcare Provider Details

I. General information

NPI: 1720290554
Provider Name (Legal Business Name): PAULINE E. PEREA LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2745
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-8950
  • Fax: 505-272-3202
Mailing address:
  • Phone: 505-272-1476
  • Fax: 505-272-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0091801
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: