Basic Information
| Provider Information | |||||||||
| NPI: | 1184132615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | BENJAMIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12440 FIRESTONE BLVD STE 316 | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906509319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628643722 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12440 FIRESTONE BLVD STE 316 | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906509319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628643722 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2018 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.