MEDICARE: SHAWN ANTHONY PEREZ IV

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1588296339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWN ANTHONY PEREZ IV

Provider Business Mailing Address
First Line	:	1947 RUE CHATEAU
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91913-1204
Country	:	US
Telephone Number	:	619-988-2701
Fax Number	:

Provider Business Practice Location Address
First Line	:	1260 CLEVELAND AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-7326
Country	:	US
Telephone Number	:	619-988-2701
Fax Number	:

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

Provider Enumeration Date	:	02/10/2020
Last Update Date	:	12/08/2020

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Directions to “ SHAWN ANTHONY PEREZ IV ” Practice Location

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