Provider Demographics
NPI:1912879404
Name:PEREZ ROSABAL, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PEREZ ROSABAL
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 1:27101 SW 138TH AVE APT C
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8064
Mailing Address - Country:US
Mailing Address - Phone:786-450-3402
Mailing Address - Fax:
Practice Address - Street 1:27101 SW 138TH AVE APT C
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-8064
Practice Address - Country:US
Practice Address - Phone:786-450-3402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician