Basic Information
| Provider Information | |||||||||
| NPI: | 1992798821 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERUZZI | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4567 CROSSROADS PARK DR | ||||||||
| Address2: | 2ND FL | ||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130883589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152952100 | ||||||||
| FaxNumber: | 3152952126 | ||||||||
| Practice Location | |||||||||
| Address1: | 9116 RIVER RD | ||||||||
| Address2: | |||||||||
| City: | MARCY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134032064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157926628 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 09/13/2007 | ||||||||
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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 | 103T00000X | 062971 1 | NY | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 02569639 | 05 | NY | MEDICAID |