Provider Demographics
NPI:1558044073
Name:PASTRANA PEREZ, JUAN C
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:PASTRANA PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 W 30TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4853
Mailing Address - Country:US
Mailing Address - Phone:561-388-3847
Mailing Address - Fax:
Practice Address - Street 1:1307 W 30TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4853
Practice Address - Country:US
Practice Address - Phone:561-388-3847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-286088106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-23-286088OtherBACB FLORIDA