Provider Demographics
NPI:1649923962
Name:PEREZ, SUSANA (CBHCM-P)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:CBHCM-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 NW 97TH AVE APT 114
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:191 NW 97TH AVE APT 114
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-4116
Practice Address - Country:US
Practice Address - Phone:786-372-2133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCM-P102505251B00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP625-780-85-669-0OtherCREDENTIAL NUMBER