Provider Demographics
NPI:1588296339
Name:PEREZ, SHAWN ANTHONY IV
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:ANTHONY
Last Name:PEREZ
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1947 RUE CHATEAU
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1204
Mailing Address - Country:US
Mailing Address - Phone:619-988-2701
Mailing Address - Fax:
Practice Address - Street 1:1260 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-7326
Practice Address - Country:US
Practice Address - Phone:619-988-2701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician