Provider Demographics
NPI:1326871773
Name:PEREZ MENDOZA, LIZ AMANDA
Entity type:Individual
Prefix:
First Name:LIZ
Middle Name:AMANDA
Last Name:PEREZ MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7260 NW 114TH AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-5575
Mailing Address - Country:US
Mailing Address - Phone:305-216-2788
Mailing Address - Fax:
Practice Address - Street 1:7260 NW 114TH AVE APT 208
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-5575
Practice Address - Country:US
Practice Address - Phone:305-216-2788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-334970106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty