Provider Demographics
NPI:1871916924
Name:PERU, JULIE (COTA)
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:
Last Name:PERU
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MRS
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:HUERTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:900 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BAYARD
Mailing Address - State:NM
Mailing Address - Zip Code:88023
Mailing Address - Country:US
Mailing Address - Phone:575-537-4000
Mailing Address - Fax:575-537-3921
Practice Address - Street 1:900 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BAYARD
Practice Address - State:NM
Practice Address - Zip Code:88023
Practice Address - Country:US
Practice Address - Phone:575-537-4000
Practice Address - Fax:575-537-3921
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2131224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000L1871Medicaid