MEDICARE: ETHEL PEREZ LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	088700-1	NY

General Provider Information

NPI Number	:	1053871079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHEL PEREZ LMSW

Provider Business Mailing Address
First Line	:	751 FOREST AVE APT 1A
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10456-7848
Country	:	US
Telephone Number	:	646-359-6773
Fax Number	:

Provider Business Practice Location Address
First Line	:	3289 THIRD AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10456-6701
Country	:	US
Telephone Number	:	718-665-8908
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2019
Last Update Date	:	03/25/2019

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