Provider Demographics
NPI:1366109001
Name:PEREZ, MAYRA CECILIA (MSW)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:CECILIA
Last Name:PEREZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 55TH ST SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-2306
Mailing Address - Country:US
Mailing Address - Phone:505-917-1648
Mailing Address - Fax:
Practice Address - Street 1:1317 ISLETA BLVD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-4035
Practice Address - Country:US
Practice Address - Phone:505-917-1648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX11826101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC236Medicaid