MEDICARE: MV PERERA LICENSED CLINICAL SOCIAL WORKER, INC.

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	106H00000X	Marriage & Family Therapist
2	1041C0700X	Clinical Social Worker	24260	CA

General Provider Information

NPI Number	:	1538662432
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MV PERERA LICENSED CLINICAL SOCIAL WORKER, INC.

Provider Business Mailing Address
First Line	:	8475 BLUE MAIDEN CT
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95624-3897
Country	:	US
Telephone Number	:	916-947-5279
Fax Number	:	530-852-0944

Provider Business Practice Location Address
First Line	:	3332 HEIGHTS DR STE 235
Second Line	:
City	:	CAMERON PARK
State	:	CA
Zip	:	95682-7774
Country	:	US
Telephone Number	:	916-947-5279
Fax Number	:	530-852-0944

Authorized Official
Title or Position	:	CEO
Name	:	MANOJ V PERERA
Credential	:	LCSW
Telephone Number	:	916-947-5279

Provider Enumeration Date	:	03/16/2018
Last Update Date	:	03/16/2018

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