Healthcare Provider Details

I. General information

NPI: 1952953259
Provider Name (Legal Business Name): IDANIS PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21465 SW 112TH AVE UNIT 203
CUTLER BAY FL
33189-2911
US

IV. Provider business mailing address

8275 SW 152ND AVE PH 4
MIAMI FL
33193-4046
US

V. Phone/Fax

Practice location:
  • Phone: 786-970-0458
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ13720
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: