Basic Information
| Provider Information | |||||||||
| NPI: | 1215000674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREA | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MSW LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 668 S BAYFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO WEST | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810072798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195440877 | ||||||||
| FaxNumber: | 7195442033 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 W 13TH ST | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195440877 | ||||||||
| FaxNumber: | 7195442033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 992752 | CO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.