Provider Demographics
NPI:1609508449
Name:PEREZ, MIGNA
Entity type:Individual
Prefix:
First Name:MIGNA
Middle Name:
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 1:100 FULKERSON DR APT 35
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-1442
Mailing Address - Country:US
Mailing Address - Phone:203-707-4345
Mailing Address - Fax:
Practice Address - Street 1:544 STRAITS TPKE STE 3
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-3340
Practice Address - Country:US
Practice Address - Phone:203-707-4345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2024-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101YM0800X
CT142131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health