Provider Demographics
NPI:1558717736
Name:PEREZ, CARLOS JESUS
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:JESUS
Last Name: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 1:3335 NE 13TH CIRCLE DR UNIT 105
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-6150
Mailing Address - Country:US
Mailing Address - Phone:786-234-2542
Mailing Address - Fax:
Practice Address - Street 1:3335 NE 13TH CIRCLE DR UNIT 105
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-6150
Practice Address - Country:US
Practice Address - Phone:786-234-2542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2022-03-30
Deactivation Date:2022-03-17
Deactivation Code:
Reactivation Date:2022-03-30
Provider Licenses
StateLicense IDTaxonomies
FLRBT-16-12759106S00000X
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty