Provider Demographics
NPI:1972896348
Name:PEREZ GONZALEZ, MIRLLEINS (MS- SLP)
Entity type:Individual
Prefix:MS
First Name:MIRLLEINS
Middle Name:
Last Name:PEREZ GONZALEZ
Suffix:
Gender:F
Credentials:MS- SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9290 HAMMOCKS BLVD STE 401
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-1347
Mailing Address - Country:US
Mailing Address - Phone:786-800-4510
Mailing Address - Fax:
Practice Address - Street 1:9290 HAMMOCKS BLVD STE 401
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-1347
Practice Address - Country:US
Practice Address - Phone:786-558-5694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2023-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14128252Y00000X
FLSA 14128235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013546100Medicaid
FL010506800Medicaid