Provider Demographics
NPI:1053935353
Name:PEREZ, DIVINA ELISE
Entity type:Individual
Prefix:
First Name:DIVINA
Middle Name:ELISE
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 1:1511 E HAZELTINE ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-7243
Mailing Address - Country:US
Mailing Address - Phone:909-215-1216
Mailing Address - Fax:909-203-7403
Practice Address - Street 1:5TH STREET & WESTERN
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860
Practice Address - Country:US
Practice Address - Phone:951-737-2683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-02
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health