Provider Demographics
NPI:1952163198
Name:PEREZ C., ANDRES MIGUEL
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:MIGUEL
Last Name:PEREZ C.
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 1:1018 N 17TH AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-3696
Mailing Address - Country:US
Mailing Address - Phone:786-630-1434
Mailing Address - Fax:
Practice Address - Street 1:13195 SW 134TH ST STE 201
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4585
Practice Address - Country:US
Practice Address - Phone:786-206-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-303119106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician