Provider Demographics
NPI:1871741553
Name:PEREZ, RUDOLPHO (MSW INTERN)
Entity type:Individual
Prefix:
First Name:RUDOLPHO
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:MSW INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 S. SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230
Mailing Address - Country:US
Mailing Address - Phone:310-412-4191
Mailing Address - Fax:
Practice Address - Street 1:1007 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301
Practice Address - Country:US
Practice Address - Phone:310-412-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA917511041C0700X
CA89427104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker