Provider Demographics
NPI:1811430291
Name:PEREZ, STACEY (MS, MHC-LP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:MS, MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 AVENUE OF THE AMERICAS FL 7
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-2022
Mailing Address - Country:US
Mailing Address - Phone:646-628-7158
Mailing Address - Fax:
Practice Address - Street 1:2090 ADAM CLAYTON POWELL JR BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-4990
Practice Address - Country:US
Practice Address - Phone:646-628-7158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-02
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP03598101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health