Provider Demographics
NPI:1396861829
Name:PEREZ-ILLADE, CARMEN (IMH)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:PEREZ-ILLADE
Suffix:
Gender:F
Credentials:IMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2802 ALOMA AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3532
Mailing Address - Country:US
Mailing Address - Phone:407-430-6300
Mailing Address - Fax:407-628-3300
Practice Address - Street 1:2802 ALOMA AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3532
Practice Address - Country:US
Practice Address - Phone:407-430-6300
Practice Address - Fax:407-628-3300
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9110101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11758066OtherCAQH