Provider Demographics
NPI:1427825132
Name:PENG SIMON, INDIOMI
Entity type:Individual
Prefix:
First Name:INDIOMI
Middle Name:
Last Name:PENG SIMON
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 1:3764 NE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-7465
Mailing Address - Country:US
Mailing Address - Phone:786-586-2981
Mailing Address - Fax:
Practice Address - Street 1:1476 N HOMESTEAD BLVD
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-5008
Practice Address - Country:US
Practice Address - Phone:786-339-8524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-272338106S00000X
FLSI67872355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician