Basic Information
| Provider Information | |||||||||
| NPI: | 1245985142 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERDOMO | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | PSYCHOLOGIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12736 CORDYLINE WAY | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957426726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269223518 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4001 CA 104 HWY | ||||||||
| Address2: | |||||||||
| City: | IONE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092744911 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2022 | ||||||||
| LastUpdateDate: | 02/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.