Provider Demographics
NPI:1215552963
Name:PEREA, RAQUEL ELAN
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:ELAN
Last Name:PEREA
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 1:15 BUCKBOARD DR
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:MT
Mailing Address - Zip Code:59749-9686
Mailing Address - Country:US
Mailing Address - Phone:504-478-8868
Mailing Address - Fax:
Practice Address - Street 1:4460 S HIGHLAND DR STE 210
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3550
Practice Address - Country:US
Practice Address - Phone:888-949-4864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator