Provider Demographics
NPI:1326653007
Name:MEJIAS PEREZ, DIANA ROSA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:ROSA
Last Name:MEJIAS PEREZ
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 1:2948 NW 180TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-3483
Mailing Address - Country:US
Mailing Address - Phone:305-619-4008
Mailing Address - Fax:
Practice Address - Street 1:2948 NW 180TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-3483
Practice Address - Country:US
Practice Address - Phone:305-619-4008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-134185106E00000X
FL172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20-134185OtherBACB