Provider Demographics
NPI:1902543895
Name:PEREZ, LISA MARIE (EDS)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 N ORLANDO AVE APT 143
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4453
Mailing Address - Country:US
Mailing Address - Phone:323-252-3690
Mailing Address - Fax:
Practice Address - Street 1:955 N ORLANDO AVE APT 143
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4453
Practice Address - Country:US
Practice Address - Phone:323-252-3690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1311937103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool