Provider Demographics
NPI:1912057597
Name:PERALTA, CARMELINA (PHD)
Entity type:Individual
Prefix:MS
First Name:CARMELINA
Middle Name:
Last Name:PERALTA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:
Other - Last Name:PERALTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:4 HUNTINGTON RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-1703
Mailing Address - Country:US
Mailing Address - Phone:631-271-3319
Mailing Address - Fax:
Practice Address - Street 1:4 HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-1703
Practice Address - Country:US
Practice Address - Phone:631-271-3319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011594103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01913744Medicaid