Provider Demographics
NPI:1578383279
Name:PERDOMO GARCIA, GIANNI
Entity type:Individual
Prefix:
First Name:GIANNI
Middle Name:
Last Name:PERDOMO GARCIA
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 1:15442 SW 115TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-6310
Mailing Address - Country:US
Mailing Address - Phone:305-874-9135
Mailing Address - Fax:
Practice Address - Street 1:15442 SW 115TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-6310
Practice Address - Country:US
Practice Address - Phone:305-874-9135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-384261106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty