Provider Demographics
NPI:1083872295
Name:PEREZ, MADIANE (LMHC, BCBA)
Entity Type:Individual
Prefix:
First Name:MADIANE
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:LMHC, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12150 SW 128TH CT STE 108
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4648
Mailing Address - Country:US
Mailing Address - Phone:786-732-0607
Mailing Address - Fax:786-732-0637
Practice Address - Street 1:12150 SW 128TH CT STE 108
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4648
Practice Address - Country:US
Practice Address - Phone:786-732-0607
Practice Address - Fax:786-732-0637
Is Sole Proprietor?:No
Enumeration Date:2008-05-26
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10803101YM0800X
FL1-15-21083103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003762900Medicaid