Healthcare Provider Details

I. General information

NPI: 1588714737
Provider Name (Legal Business Name): VIVIAN M PERALTA MESA MS, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 15TH AVE STE F
LONGVIEW WA
98632-3080
US

IV. Provider business mailing address

1105 15TH AVE STE F
LONGVIEW WA
98632-3080
US

V. Phone/Fax

Practice location:
  • Phone: 704-910-7942
  • Fax:
Mailing address:
  • Phone: 704-910-7942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4516
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1297
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLF61566719
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: