Provider Demographics
NPI:1952894552
Name:PEREZ, BALBINO
Entity type:Individual
Prefix:
First Name:BALBINO
Middle Name:
Last Name:PEREZ
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 1:368 N SHADOWBAY BLVD
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4420
Mailing Address - Country:US
Mailing Address - Phone:407-717-3676
Mailing Address - Fax:
Practice Address - Street 1:368 N SHADOWBAY BLVD
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4420
Practice Address - Country:US
Practice Address - Phone:407-717-3676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP626-060-78-259-0104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker