Provider Demographics
NPI:1316412638
Name:PEREZ DIAZ, ILEANA (RBT)
Entity type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:PEREZ DIAZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 NW 128TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-1876
Mailing Address - Country:US
Mailing Address - Phone:786-803-7038
Mailing Address - Fax:
Practice Address - Street 1:11890 SW 8TH ST STE 309
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-1710
Practice Address - Country:US
Practice Address - Phone:305-220-6060
Practice Address - Fax:888-247-5059
Is Sole Proprietor?:No
Enumeration Date:2018-10-13
Last Update Date:2018-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-53392106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-18-53392Medicaid
FLRBT-18-53392Medicaid