MEDICARE: GINA LEE PEREZ BSW

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		CO

General Provider Information

NPI Number	:	1689157257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA LEE PEREZ BSW

Provider Business Mailing Address
First Line	:	1600 SPECHT POINT RD STE 105
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-4311
Country	:	US
Telephone Number	:	970-692-7450
Fax Number	:

Provider Business Practice Location Address
First Line	:	825 DELAWARE AVE # 205
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80501-6169
Country	:	US
Telephone Number	:	970-305-0948
Fax Number	:

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

Provider Enumeration Date	:	09/10/2018
Last Update Date	:	09/10/2018

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