Provider Demographics
NPI:1821751553
Name:PEREZ RODRIGUEZ, MIRIAM LILIANA (BEHAVIOR THERAPY)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:LILIANA
Last Name:PEREZ RODRIGUEZ
Suffix:
Gender:F
Credentials:BEHAVIOR THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13804 SW 26TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-6576
Mailing Address - Country:US
Mailing Address - Phone:786-381-5864
Mailing Address - Fax:
Practice Address - Street 1:6405 NW 36TH ST STE 100
Practice Address - Street 2:
Practice Address - City:VIRGINIA GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33166-6977
Practice Address - Country:US
Practice Address - Phone:786-953-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-116958106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103337400Medicaid