Provider Demographics
NPI:1073019865
Name:HURTADO PEREZ, GILBERTO
Entity Type:Individual
Prefix:
First Name:GILBERTO
Middle Name:
Last Name:HURTADO PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2724 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-3846
Mailing Address - Country:US
Mailing Address - Phone:786-580-9262
Mailing Address - Fax:
Practice Address - Street 1:18645 SW 291ST ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-3056
Practice Address - Country:US
Practice Address - Phone:786-580-9262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-21-57311103K00000X
FL0-20-11281106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019624600Medicaid