Provider Demographics
NPI:1952865594
Name:GAINZA PEREZ, JOSE LUIS
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:GAINZA 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 1:320 SE 11TH AVE APT 310
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-7409
Mailing Address - Country:US
Mailing Address - Phone:954-422-3242
Mailing Address - Fax:
Practice Address - Street 1:320 SE 11TH AVE APT 301
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-7409
Practice Address - Country:US
Practice Address - Phone:954-422-3242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-71092106S00000X
FL1-24-71899103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103130200Medicaid