Provider Demographics
NPI:1700293032
Name:PEREZ, LISANDRA (OTA)
Entity Type:Individual
Prefix:
First Name:LISANDRA
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:LISANDRA
Other - Middle Name:
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTA
Mailing Address - Street 1:17800 NW 73RD AVE APT 103
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-6217
Mailing Address - Country:US
Mailing Address - Phone:786-239-1310
Mailing Address - Fax:
Practice Address - Street 1:12741 SW 17TH CT
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-2500
Practice Address - Country:US
Practice Address - Phone:954-447-8844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 12116224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant