Provider Demographics
NPI:1104071471
Name:PEREZ, GUSTAVO JOAQUIN (PHD)
Entity type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:JOAQUIN
Last Name:PEREZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 N WILMOT RD STE 201
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2629
Mailing Address - Country:US
Mailing Address - Phone:520-343-1777
Mailing Address - Fax:520-694-2185
Practice Address - Street 1:535 N WILMOT RD STE 201
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2629
Practice Address - Country:US
Practice Address - Phone:520-343-1777
Practice Address - Fax:520-694-2185
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3976103T00000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool