Provider Demographics
NPI:1912492588
Name:PEREZ, MINDRA ASHLEY
Entity Type:Individual
Prefix:
First Name:MINDRA
Middle Name:ASHLEY
Last Name: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:PO BOX 1088
Mailing Address - Street 2:
Mailing Address - City:BUNNELL
Mailing Address - State:FL
Mailing Address - Zip Code:32110-1088
Mailing Address - Country:US
Mailing Address - Phone:386-270-2664
Mailing Address - Fax:
Practice Address - Street 1:56 POST VIEW DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-4948
Practice Address - Country:US
Practice Address - Phone:386-270-2664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224ZE0001X, 224ZL0004X
FLOTA13611224ZF0002X, 224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental Modification
No224ZF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantFeeding, Eating & SwallowingGroup - Single Specialty
No224ZL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantLow VisionGroup - Single Specialty