Provider Demographics
NPI:1518777119
Name:PEGUERO, GENESIS ILIANA (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:GENESIS
Middle Name:ILIANA
Last Name:PEGUERO
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:GENESIS
Other - Middle Name:ILIANA
Other - Last Name:GUERRERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13 HUNTRESS AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3934
Mailing Address - Country:US
Mailing Address - Phone:857-212-2025
Mailing Address - Fax:
Practice Address - Street 1:1 WILDCAT WAY
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-2664
Practice Address - Country:US
Practice Address - Phone:781-337-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1278721041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool