Provider Demographics
NPI:1114674108
Name:PEREZ GARCIA, CAROLIN
Entity Type:Individual
Prefix:
First Name:CAROLIN
Middle Name:
Last Name:PEREZ GARCIA
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 1:158 MAGIC LANDINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-5514
Mailing Address - Country:US
Mailing Address - Phone:786-985-9713
Mailing Address - Fax:
Practice Address - Street 1:158 MAGIC LANDINGS BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5514
Practice Address - Country:US
Practice Address - Phone:786-985-9713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113341900Medicaid