Provider Demographics
NPI:1124451448
Name:PERATA, ELYSE (MS)
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:PERATA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 BURBANK DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-2960
Mailing Address - Country:US
Mailing Address - Phone:510-390-1929
Mailing Address - Fax:
Practice Address - Street 1:1430 WILLOW PASS RD STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-7946
Practice Address - Country:US
Practice Address - Phone:925-288-3902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-11
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102659106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist