Provider Demographics
NPI:1962257386
Name:PELAEZ, OMAR JR
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:PELAEZ
Suffix:JR
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 1:12232 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2439
Mailing Address - Country:US
Mailing Address - Phone:305-316-7537
Mailing Address - Fax:
Practice Address - Street 1:2500 QUANTUM LAKES DR STE 203
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-8323
Practice Address - Country:US
Practice Address - Phone:561-409-8240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-337738106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician