Provider Demographics
NPI:1124366430
Name:PEREZ, MARILOURDES (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:MARILOURDES
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 S NOVA RD STE 303
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9293
Mailing Address - Country:US
Mailing Address - Phone:386-310-7436
Mailing Address - Fax:386-259-6112
Practice Address - Street 1:3930 S NOVA RD STE 303
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9293
Practice Address - Country:US
Practice Address - Phone:386-310-7436
Practice Address - Fax:386-259-6112
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-21
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13815101YM0800X
ZZMH13815101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health