MEDICARE: MS. VIVIAN M PERALTA MESA MS, LMFT

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	4516	SC
2	106H00000X	Marriage & Family Therapist	1297	NC
3	106H00000X	Marriage & Family Therapist	LF61566719	WA

General Provider Information

NPI Number	:	1588714737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VIVIAN M PERALTA MESA MS, LMFT

Provider Business Mailing Address
First Line	:	1105 15TH AVE STE F
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-3080
Country	:	US
Telephone Number	:	704-910-7942
Fax Number	:

Provider Business Practice Location Address
First Line	:	1105 15TH AVE STE F
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-3080
Country	:	US
Telephone Number	:	704-910-7942
Fax Number	:

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

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	06/16/2026

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