Provider Demographics
NPI:1922869833
Name:PEREZ, ERNESTO OLIVIER
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:OLIVIER
Last Name: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 1:2354 SW NEAL RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5788
Mailing Address - Country:US
Mailing Address - Phone:786-843-0461
Mailing Address - Fax:
Practice Address - Street 1:906 SEMINOLE DR
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-7648
Practice Address - Country:US
Practice Address - Phone:772-216-2501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician