MEDICARE: JOHANNA LISSETTE PERALTA 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	101876-01	NY

General Provider Information

NPI Number	:	1932969599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHANNA LISSETTE PERALTA LMSW

Provider Business Mailing Address
First Line	:	1526 JARVIS AVE FL 2
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-5605
Country	:	US
Telephone Number	:	929-253-1813
Fax Number	:

Provider Business Practice Location Address
First Line	:	1526 JARVIS AVE FL 2
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-5605
Country	:	US
Telephone Number	:	929-253-1813
Fax Number	:

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

Provider Enumeration Date	:	03/20/2024
Last Update Date	:	03/20/2024

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