Provider Demographics
NPI:1770054546
Name:MEDINA PEREZ, MISLEIVIS
Entity type:Individual
Prefix:
First Name:MISLEIVIS
Middle Name:
Last Name:MEDINA PEREZ
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 1:15451 SW 80TH ST APT 105
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2614
Mailing Address - Country:US
Mailing Address - Phone:786-355-3038
Mailing Address - Fax:
Practice Address - Street 1:11890 SW 8TH ST STE 309
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-1710
Practice Address - Country:US
Practice Address - Phone:305-220-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022396200Medicaid