Provider Demographics
NPI:1275366833
Name:PERDOMO, SOFIA LISSETH
Entity type:Individual
Prefix:
First Name:SOFIA
Middle Name:LISSETH
Last Name:PERDOMO
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 1:4747 LIVE OAK ST
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:CA
Mailing Address - Zip Code:90201-5113
Mailing Address - Country:US
Mailing Address - Phone:323-572-7023
Mailing Address - Fax:
Practice Address - Street 1:4747 LIVE OAK ST
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:CA
Practice Address - Zip Code:90201-5113
Practice Address - Country:US
Practice Address - Phone:323-572-7023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst