Provider Demographics
NPI:1417570755
Name:PERDOMO DO VALE, MIRIAM ILIANA
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:ILIANA
Last Name:PERDOMO DO VALE
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 1:631 SW 111TH LN
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-6932
Mailing Address - Country:US
Mailing Address - Phone:954-515-9332
Mailing Address - Fax:
Practice Address - Street 1:631 SW 111TH LN
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-6932
Practice Address - Country:US
Practice Address - Phone:954-515-9332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-117702106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician