Provider Demographics
NPI:1699251595
Name:PERDOMO CARMONA, ILEN
Entity type:Individual
Prefix:
First Name:ILEN
Middle Name:
Last Name:PERDOMO CARMONA
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 1:3799 SW 148TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-3901
Mailing Address - Country:US
Mailing Address - Phone:786-879-9550
Mailing Address - Fax:
Practice Address - Street 1:3799 SW 148TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185-3901
Practice Address - Country:US
Practice Address - Phone:786-879-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLRBT1867920106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022422300Medicaid