Basic Information
| Provider Information | |||||||||
| NPI: | 1326079088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREZ - LANE | ||||||||
| FirstName: | AWILDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 MAIN ST APT 126 | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076015743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2013158140 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 156 W 56TH ST STE 1804 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100193878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128518100 | ||||||||
| FaxNumber: | 2125370102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0700X | 35SI100429700 | NJ | N | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | 103TC0700X | 013880 | NJ | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 013880 | 01 | NJ | LICENSE | OTHER |