Provider Demographics
NPI:1114633138
Name:PEREIRA HERNANDEZ, CHANEL
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:PEREIRA HERNANDEZ
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 1:941 SE WALTERS TER
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3931
Mailing Address - Country:US
Mailing Address - Phone:772-882-8245
Mailing Address - Fax:
Practice Address - Street 1:941 SE WALTERS TER
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-3931
Practice Address - Country:US
Practice Address - Phone:772-882-8245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-248246106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician