Provider Demographics
NPI:1609426055
Name:ROMERO PEREZ, ILUMINADA DE LAS MERCEDES (REGISTER BEHAVIOR TE)
Entity Type:Individual
Prefix:
First Name:ILUMINADA
Middle Name:DE LAS MERCEDES
Last Name:ROMERO PEREZ
Suffix:
Gender:F
Credentials:REGISTER BEHAVIOR TE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1865 W 72ND ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-4446
Mailing Address - Country:US
Mailing Address - Phone:786-380-3738
Mailing Address - Fax:
Practice Address - Street 1:1865 W 72ND ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-4446
Practice Address - Country:US
Practice Address - Phone:786-380-3738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT1873573106S00000X
FL18-73573106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021698800Medicaid