Provider Demographics
NPI:1194582510
Name:JUNCO PEREZ, LUIS JAVIER
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:JAVIER
Last Name:JUNCO PEREZ
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 1:14645 SW 96TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-6912
Mailing Address - Country:US
Mailing Address - Phone:305-915-1794
Mailing Address - Fax:
Practice Address - Street 1:2615 FAIRWAYS DR
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33035-1173
Practice Address - Country:US
Practice Address - Phone:786-224-4525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-01
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-328915106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician