Provider Demographics
NPI:1124861018
Name:PEREZ LEYVA, RAFAEL ANTONIO
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:ANTONIO
Last Name:PEREZ LEYVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 NW 78TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33147-5538
Mailing Address - Country:US
Mailing Address - Phone:786-538-6742
Mailing Address - Fax:
Practice Address - Street 1:2360 NW 78TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33147-5538
Practice Address - Country:US
Practice Address - Phone:786-538-6742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-348016106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician