Provider Demographics
NPI:1528554482
Name:PERDOMO, TAMEKA
Entity Type:Individual
Prefix:
First Name:TAMEKA
Middle Name:
Last Name:PERDOMO
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 1:531 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FLORIDA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33034-2053
Mailing Address - Country:US
Mailing Address - Phone:305-942-5281
Mailing Address - Fax:
Practice Address - Street 1:3390 NE 13TH CIRCLE DR UNIT 105
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-6148
Practice Address - Country:US
Practice Address - Phone:305-632-9257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-03
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
16611101YM0800X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021629900Medicaid