Provider Demographics
NPI:1932957750
Name:PEREZ FERNANDEZ, LEODAN
Entity Type:Individual
Prefix:
First Name:LEODAN
Middle Name:
Last Name:PEREZ FERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 CLAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33972-7301
Mailing Address - Country:US
Mailing Address - Phone:786-491-3360
Mailing Address - Fax:
Practice Address - Street 1:1119 CLAYTON AVE
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33972-7301
Practice Address - Country:US
Practice Address - Phone:786-491-3360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician