Provider Demographics
NPI:1467206425
Name:PEREZ PENA, SORISLAIDYS
Entity Type:Individual
Prefix:
First Name:SORISLAIDYS
Middle Name:
Last Name:PEREZ PENA
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 1:1251 SE 31ST CT UNIT 202
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33035-2369
Mailing Address - Country:US
Mailing Address - Phone:305-798-8786
Mailing Address - Fax:
Practice Address - Street 1:1251 SE 31ST CT UNIT 202
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33035-2369
Practice Address - Country:US
Practice Address - Phone:305-798-8786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-339505106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician