=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558635805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARMEN PEREZ-ILLADE LMHC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2012
-----------------------------------------------------
Last Update Date | 03/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2802 ALOMA AVE SUITE 102
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32792-3532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-430-6300
-----------------------------------------------------
Fax | 407-628-3300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2802 ALOMA AVE SUITE 102
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32792-3532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-430-6300
-----------------------------------------------------
Fax | 407-628-3300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | CARMEN PEREZ-ILLADE
-----------------------------------------------------
Credential | MA, NCC, LMHC
-----------------------------------------------------
Telephone | 407-430-6300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | MH9110
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------