Provider Demographics
NPI:1730356734
Name:PEREZ, DIANA A (WSC)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:A
Last Name:PEREZ
Suffix:
Gender:F
Credentials:WSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6635 SW 46TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-5903
Mailing Address - Country:US
Mailing Address - Phone:305-669-4795
Mailing Address - Fax:305-669-4413
Practice Address - Street 1:6635 SW 46TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-5903
Practice Address - Country:US
Practice Address - Phone:305-669-4795
Practice Address - Fax:305-669-4413
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689900596Medicaid
FL689900598Medicaid