Basic Information
| Provider Information | |||||||||
| NPI: | 1861687345 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERALES | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 FRUITVALE AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946012322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105356200 | ||||||||
| FaxNumber: | 5105354167 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 FRUITVALE AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946012322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105356200 | ||||||||
| FaxNumber: | 5105354167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2007 | ||||||||
| LastUpdateDate: | 09/01/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | ASW 66274 | CA | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | ZZZ29799Z | 01 | CA | FQHC MEDICARE PART B | OTHER | 05-1063 | 01 | CA | FQHC MEDICARE PART A | OTHER |