Provider Demographics
NPI:1588714737
Name:PERALTA MESA, VIVIAN M (MS, LMFT)
Entity type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:M
Last Name:PERALTA MESA
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 MARKET ST STE 82
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3737
Mailing Address - Country:US
Mailing Address - Phone:704-910-7942
Mailing Address - Fax:
Practice Address - Street 1:748 MARKET ST STE 82
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3737
Practice Address - Country:US
Practice Address - Phone:704-910-7942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2024-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1297106H00000X
WALF61566719106H00000X
SC4516106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist