Provider Demographics
NPI:1588474969
Name:PEREZ PENA, JUAN
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:PEREZ PENA
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 1:3149 BEE RIDGE RD APT 27
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-7138
Mailing Address - Country:US
Mailing Address - Phone:305-360-3236
Mailing Address - Fax:
Practice Address - Street 1:4509 BEE RIDGE RD UNIT E
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-2539
Practice Address - Country:US
Practice Address - Phone:941-914-5272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-25-403286106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician