Provider Demographics
NPI:1104240688
Name:PERALTA, CLARISSA AMOR (LCSW)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:AMOR
Last Name:PERALTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 WATERMAN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48209-2022
Mailing Address - Country:US
Mailing Address - Phone:915-613-7674
Mailing Address - Fax:
Practice Address - Street 1:1700 WATERMAN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48209-2022
Practice Address - Country:US
Practice Address - Phone:915-613-7674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-05
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX611131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical