Healthcare Provider Details

I. General information

NPI: 1750709416
Provider Name (Legal Business Name): CONCEPCION PEREZ EBRAHIMI M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 NW UNIVERSITY BLVD SUITE202
PORT SAINT LUCIE FL
34986-2286
US

IV. Provider business mailing address

4740 N STATE ROAD 7 201
LAUDERDALE LAKES FL
33319-5839
US

V. Phone/Fax

Practice location:
  • Phone: 772-361-6767
  • Fax: 954-497-3857
Mailing address:
  • Phone: 954-486-4005
  • Fax: 954-497-3857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: