Provider Demographics
NPI:1477306413
Name:PEROZO, LUIS RAFAEL (CBHCMS)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:RAFAEL
Last Name:PEROZO
Suffix:
Gender:M
Credentials:CBHCMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 S UNIVERSITY DR STE 204C
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-5308
Mailing Address - Country:US
Mailing Address - Phone:954-906-5947
Mailing Address - Fax:786-329-6876
Practice Address - Street 1:5220 S UNIVERSITY DR STE 204C
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-5308
Practice Address - Country:US
Practice Address - Phone:954-906-5947
Practice Address - Fax:786-329-6876
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL01027006171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator