Healthcare Provider Details

I. General information

NPI: 1053248914
Provider Name (Legal Business Name): LEIDYS MARIA PEREZ VENEGAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 SE HILLMOOR DR STE B101-103
PORT SAINT LUCIE FL
34952-7553
US

IV. Provider business mailing address

1925 ROYAL PALM DR
FORT PIERCE FL
34982-5626
US

V. Phone/Fax

Practice location:
  • Phone: 772-463-0444
  • Fax: 772-219-1339
Mailing address:
  • Phone: 561-324-0238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: