Healthcare Provider Details

I. General information

NPI: 1841283207
Provider Name (Legal Business Name): SUSAN J. PERRY PH.D.,CDC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 CORONADO AVE
ESPANOLA NM
87532-2725
US

IV. Provider business mailing address

111 N RAILROAD AVE P.O. BOX 158
ESPANOLA NM
87532-2627
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-7395
  • Fax: 505-753-8373
Mailing address:
  • Phone: 505-753-7218
  • Fax: 505-753-5815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2874
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: