Basic Information
| Provider Information | |||||||||
| NPI: | 1215352620 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERRY | ||||||||
| FirstName: | LIVIA | ||||||||
| MiddleName: | CSONKA MARTA | ||||||||
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| Credential: | N.P. | ||||||||
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| OtherLastName: | CSONKA | ||||||||
| OtherFirstName: | LIVIA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2552 1/2 N TOWNE AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672251 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1517 W GARVEY AVE N | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917902138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269626061 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2014 | ||||||||
| LastUpdateDate: | 09/24/2014 | ||||||||
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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 | 163WP0809X | 759829 | CA | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 363LP0808X | 95001053 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.