Healthcare Provider Details

I. General information

NPI: 1962230334
Provider Name (Legal Business Name): TIMOTHY PEREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11315 CORPORATE BLVD STE 105
ORLANDO FL
32817-8340
US

IV. Provider business mailing address

1000 HOLT AVE # 2737
WINTER PARK FL
32789-4499
US

V. Phone/Fax

Practice location:
  • Phone: 407-534-0186
  • Fax: 321-972-3982
Mailing address:
  • Phone: 407-417-5161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: