Provider Demographics
NPI:1710635172
Name:PEREZ MEDINA, FLOR E
Entity Type:Individual
Prefix:
First Name:FLOR
Middle Name:E
Last Name:PEREZ MEDINA
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 1:6620 W 2ND CT APT 113
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6701
Mailing Address - Country:US
Mailing Address - Phone:786-616-5802
Mailing Address - Fax:
Practice Address - Street 1:6620 W 2ND CT APT 113
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6701
Practice Address - Country:US
Practice Address - Phone:786-616-5802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-122860106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician