Provider Demographics
NPI:1144928169
Name:PEREA, ANGEL S (LMT, CMMP, CMMT, CES)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:S
Last Name:PEREA
Suffix:
Gender:M
Credentials:LMT, CMMP, CMMT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 W TURNEY AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2835
Mailing Address - Country:US
Mailing Address - Phone:808-979-1262
Mailing Address - Fax:
Practice Address - Street 1:2394 E CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3429
Practice Address - Country:US
Practice Address - Phone:808-979-1262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-23643225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist