Provider Demographics
NPI:1104695352
Name:AMPUDIA PEREZ, MANUEL ENRIQUE (RBT)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:ENRIQUE
Last Name:AMPUDIA PEREZ
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11006 WINGATE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-5234
Mailing Address - Country:US
Mailing Address - Phone:656-227-0800
Mailing Address - Fax:
Practice Address - Street 1:11006 WINGATE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-5234
Practice Address - Country:US
Practice Address - Phone:656-227-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-29
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-314736106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician