Healthcare Provider Details

I. General information

NPI: 1336765460
Provider Name (Legal Business Name): MICHAEL GABRIEL PEREZ LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10250 SW 56TH ST STE C
MIAMI FL
33165-7069
US

IV. Provider business mailing address

12204 SW 95TH ST
MIAMI FL
33186-1927
US

V. Phone/Fax

Practice location:
  • Phone: 305-271-8509
  • Fax:
Mailing address:
  • Phone: 305-491-2903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW17166
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: