Provider Demographics
NPI:1447841143
Name:PEREZ, ANGELA LAURIE (MT)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:LAURIE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:LAURIE
Other - Last Name:WADFORD-PEREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MT
Mailing Address - Street 1:1834 UCCELLO AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-2938
Mailing Address - Country:US
Mailing Address - Phone:510-301-0407
Mailing Address - Fax:
Practice Address - Street 1:1834 UCCELLO AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2938
Practice Address - Country:US
Practice Address - Phone:510-301-0407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61191225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE