Provider Demographics
NPI:1073273884
Name:CAZANOLA PEREZ, MILDREY
Entity Type:Individual
Prefix:
First Name:MILDREY
Middle Name:
Last Name:CAZANOLA PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2791 S FLORIDA MANGO RD APT 114
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-2213
Mailing Address - Country:US
Mailing Address - Phone:832-567-7184
Mailing Address - Fax:
Practice Address - Street 1:2791 S FLORIDA MANGO RD APT 114
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-2213
Practice Address - Country:US
Practice Address - Phone:832-567-7184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-20
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-123041106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician