Provider Demographics
NPI:1609624204
Name:PERDOMO DIAZ, VICTOR
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:PERDOMO DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 NW 11TH ST APT 210
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-2761
Mailing Address - Country:US
Mailing Address - Phone:786-515-8324
Mailing Address - Fax:
Practice Address - Street 1:11402 NW 41ST ST UNIT 206
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-4859
Practice Address - Country:US
Practice Address - Phone:305-373-3424
Practice Address - Fax:305-373-3474
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-345669106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician