Healthcare Provider Details

I. General information

NPI: 1821547696
Provider Name (Legal Business Name): DORIS PERDOMO-JOHNSON L.M.F.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SE 3RD AVE
FORT LAUDERDALE FL
33301-1920
US

IV. Provider business mailing address

101 SE 3RD AVE
FORT LAUDERDALE FL
33301-1920
US

V. Phone/Fax

Practice location:
  • Phone: 954-463-2273
  • Fax: 954-779-1643
Mailing address:
  • Phone: 954-463-2273
  • Fax: 954-779-1643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1910
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: