Provider Demographics
NPI:1649018086
Name:PEREZ, ITZEL MONIQUE
Entity type:Individual
Prefix:
First Name:ITZEL
Middle Name:MONIQUE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ITZEL
Other - Middle Name:MONIQUE
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SCHOOL PSYCHOLOGIST
Mailing Address - Street 1:505 S MAIN ST STE 249
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1243
Mailing Address - Country:US
Mailing Address - Phone:575-527-5900
Mailing Address - Fax:575-527-5886
Practice Address - Street 1:505 S MAIN ST STE 249
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1243
Practice Address - Country:US
Practice Address - Phone:575-527-5900
Practice Address - Fax:575-527-5886
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool