=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528874658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINIQUE PERLA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2024
-----------------------------------------------------
Last Update Date | 12/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 144 NORTH RD STE 3450
-----------------------------------------------------
City | SUDBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01776-1183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-233-3054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 71 VIEW ST
-----------------------------------------------------
City | LEOMINSTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01453-2540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-857-8039
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------