Provider Demographics
NPI:1124763628
Name:LACLETTE PEREZ, TILA MARIA
Entity type:Individual
Prefix:
First Name:TILA
Middle Name:MARIA
Last Name:LACLETTE PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5242 FALKIRK AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-1572
Mailing Address - Country:US
Mailing Address - Phone:708-262-3093
Mailing Address - Fax:
Practice Address - Street 1:22445 ALESSANDRO BLVD # 113-114
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-8358
Practice Address - Country:US
Practice Address - Phone:951-924-9791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7127101YM0800X
CA117078106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health