Basic Information
| Provider Information | |||||||||
| NPI: | 1629595673 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | JOHNNY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19338 WELBY WAY | ||||||||
| Address2: | |||||||||
| City: | RESEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913354921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626865866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20151 NORDHOFF ST | ||||||||
| Address2: | |||||||||
| City: | CHATSWORTH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913116215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184073200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2017 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 778-R | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | C061540620 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.