Provider Demographics
NPI:1255912416
Name:PEREZ TEJEDA, MARINELY COROMOTO
Entity type:Individual
Prefix:
First Name:MARINELY
Middle Name:COROMOTO
Last Name:PEREZ TEJEDA
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 1:16221 ADMIRALS COVE LN
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-8401
Mailing Address - Country:US
Mailing Address - Phone:786-370-9631
Mailing Address - Fax:
Practice Address - Street 1:16221 ADMIRALS COVE LN
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-8401
Practice Address - Country:US
Practice Address - Phone:786-370-9631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-161436106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty