Provider Demographics
NPI:1477177103
Name:JIMENEZ PEREZ, LEYDI
Entity Type:Individual
Prefix:
First Name:LEYDI
Middle Name:
Last Name:JIMENEZ 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 1:11450 SW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1049
Mailing Address - Country:US
Mailing Address - Phone:305-492-3102
Mailing Address - Fax:
Practice Address - Street 1:11450 SW 5TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1049
Practice Address - Country:US
Practice Address - Phone:305-492-3102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician