Basic Information
| Provider Information | |||||||||
| NPI: | 1457814477 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | SIERRA | ||||||||
| MiddleName: | DOMONIQUE | ||||||||
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| Credential: | BA ; RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 346 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436970346 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 123 22ND ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436042706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192416191 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2019 | ||||||||
| LastUpdateDate: | 09/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | C.2204305-TRNE | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 106S00000X | RBT-18-67117 | Y |
ID Information
| ID | Type | State | Issuer | Description | RBT-18-67117 | 01 | RBT CERTIFICATE | OTHER |