Provider Demographics
NPI:1225860554
Name:LAKE PEREZ, GASPAR DIXAN
Entity type:Individual
Prefix:
First Name:GASPAR
Middle Name:DIXAN
Last Name:LAKE 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 1:12140 SW 200TH ST APT 112
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-4940
Mailing Address - Country:US
Mailing Address - Phone:305-726-7914
Mailing Address - Fax:
Practice Address - Street 1:12140 SW 200TH ST APT 112
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-4940
Practice Address - Country:US
Practice Address - Phone:305-726-7914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-369329106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty