Provider Demographics
NPI:1396100129
Name:PEREZ-ESCOBAR, VIVIAN
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:PEREZ-ESCOBAR
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 1:1763 TOWERING OAK DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-6620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1763 TOWERING OAK DR
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-6620
Practice Address - Country:US
Practice Address - Phone:941-330-4349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X
104100000X
FLSA 9620235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker