=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427520667
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISA ANN PEREZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2018
-----------------------------------------------------
Last Update Date | 12/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 TEAKETTLE SPOUT RD
-----------------------------------------------------
City | MAHOPAC
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10541-4239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-678-0294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 TEAKETTLE SPOUT RD
-----------------------------------------------------
City | MAHOPAC
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10541-4239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------