Provider Demographics
NPI:1538868062
Name:PEREZ VEGA, LIDICE
Entity type:Individual
Prefix:
First Name:LIDICE
Middle Name:
Last Name:PEREZ VEGA
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 1:4381 MISS PINEY RD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-2606
Mailing Address - Country:US
Mailing Address - Phone:714-476-1311
Mailing Address - Fax:
Practice Address - Street 1:4381 MISS PINEY RD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-2606
Practice Address - Country:US
Practice Address - Phone:714-476-1311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-258117106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician