Healthcare Provider Details

I. General information

NPI: 1063056695
Provider Name (Legal Business Name): KIM PEREZ SCHNEIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10142 HAVERHILL RIDGE DR
RIVERVIEW FL
33578-2120
US

IV. Provider business mailing address

10142 HAVERHILL RIDGE DR
RIVERVIEW FL
33578-2120
US

V. Phone/Fax

Practice location:
  • Phone: 813-340-1283
  • Fax: 813-626-0067
Mailing address:
  • Phone: 813-340-1283
  • Fax: 813-626-0067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS1056
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW00004656
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: