Provider Demographics
NPI:1245768985
Name:JEREZ, RICHARD ANTHONY
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ANTHONY
Last Name:JEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27501 S DIXIE HWY STE 200
Mailing Address - Street 2:
Mailing Address - City:NARANJA
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8219
Mailing Address - Country:US
Mailing Address - Phone:786-601-2608
Mailing Address - Fax:305-647-0250
Practice Address - Street 1:27501 S DIXIE HWY STE 403
Practice Address - Street 2:
Practice Address - City:NARANJA
Practice Address - State:FL
Practice Address - Zip Code:33032-8219
Practice Address - Country:US
Practice Address - Phone:786-601-2608
Practice Address - Fax:305-647-0250
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-25
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-74612106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician