Provider Demographics
NPI:1568234565
Name:PEREZ PUERTO, SANDY
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:
Last Name:PEREZ PUERTO
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 1:14967 NW 91ST CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33018-1345
Mailing Address - Country:US
Mailing Address - Phone:305-874-9033
Mailing Address - Fax:
Practice Address - Street 1:14967 NW 91ST CT
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33018-1345
Practice Address - Country:US
Practice Address - Phone:305-874-9033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-306135106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician