Provider Demographics
NPI:1386072650
Name:PEREZ, KENNETH ALEXANDER
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALEXANDER
Last Name: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 1:9015 SW 138TH ST APT H
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-7171
Mailing Address - Country:US
Mailing Address - Phone:786-702-3422
Mailing Address - Fax:
Practice Address - Street 1:5400 S UNIVERSITY DR STE 502
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-5313
Practice Address - Country:US
Practice Address - Phone:786-702-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-24
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-21-56168103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician