Provider Demographics
NPI:1962050559
Name:PEREZ, MARIAH KRISTINE
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:KRISTINE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S AVE K
Mailing Address - Street 2:SATION 3, SHROC
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1420 CARLISLE BLVD NE STE 100
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5662
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program