Provider Demographics
NPI:1386300929
Name:PERICO, IGNACIO (MA, LAC, LCADC, NCC)
Entity type:Individual
Prefix:
First Name:IGNACIO
Middle Name:
Last Name:PERICO
Suffix:
Gender:M
Credentials:MA, LAC, LCADC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 38TH ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-2517
Mailing Address - Country:US
Mailing Address - Phone:201-598-4344
Mailing Address - Fax:
Practice Address - Street 1:596 ANDERSON AVE STE 305
Practice Address - Street 2:
Practice Address - City:CLIFFSIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07010-1888
Practice Address - Country:US
Practice Address - Phone:201-654-4086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2024-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NJ37LC00373100101YA0400X
NJ37AC00661000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)