Provider Demographics
NPI:1740325547
Name:PERERA, JORGE (LCSW)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:PERERA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 SE 3RD AVE
Mailing Address - Street 2:THIRD FLOOR CBO-PBO
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 W. BROWARD BLVD.
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312
Practice Address - Country:US
Practice Address - Phone:954-463-7313
Practice Address - Fax:954-527-6003
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW1234104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW1234OtherLICENSE