Provider Demographics
NPI:1457064610
Name:PERDOMO ALBERNAS, MARAIVY
Entity Type:Individual
Prefix:
First Name:MARAIVY
Middle Name:
Last Name:PERDOMO ALBERNAS
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 1:741 NW 45TH AVE APT 38
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2489
Mailing Address - Country:US
Mailing Address - Phone:786-384-2650
Mailing Address - Fax:
Practice Address - Street 1:741 NW 45TH AVE APT 38
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-2489
Practice Address - Country:US
Practice Address - Phone:786-384-2650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-183342106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty