Provider Demographics
NPI:1821758228
Name:DE LA CAMPA PEREZ, ELISEO ABEL
Entity Type:Individual
Prefix:
First Name:ELISEO
Middle Name:ABEL
Last Name:DE LA CAMPA 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 1:14937 SW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33194-2504
Mailing Address - Country:US
Mailing Address - Phone:786-716-6349
Mailing Address - Fax:
Practice Address - Street 1:14937 SW 11TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33194-2504
Practice Address - Country:US
Practice Address - Phone:786-716-6349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-21-194542106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician