Basic Information
| Provider Information | |||||||||
| NPI: | 1528117769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREIRA | ||||||||
| FirstName: | EDUARDO | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1814 W 500 N | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469529107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656647364 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 101 S WASHINGTON ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469523867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656629971 | ||||||||
| FaxNumber: | 7656516566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34001263A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 000000004027 | 01 | IN | MPLAN PROV ID | OTHER | 158079 | 01 | IN | VALUE OPTIONS PROV ID | OTHER | 0005477491 | 01 | IN | AETNA PROVIDER ID | OTHER | 088367428001 | 01 | IN | GENERAL LIC # | OTHER | I014647 | 01 | IN | TRICARE PROVIDER ID | OTHER | 000000183231 | 01 | IN | ANTHEM PROVIDER ID | OTHER | LIC34001263A | 01 | IN | GENERAL MOTORS PROV ID | OTHER | 000000317611 | 01 | IN | GENCORP PROVIDER ID | OTHER |