Provider Demographics
NPI:1851892764
Name:PERICLES, FREDLYNN J
Entity type:Individual
Prefix:
First Name:FREDLYNN
Middle Name:J
Last Name:PERICLES
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 1:20110 NE 3RD CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-2962
Mailing Address - Country:US
Mailing Address - Phone:786-230-7779
Mailing Address - Fax:
Practice Address - Street 1:4008 SW 23RD ST
Practice Address - Street 2:
Practice Address - City:WEST PARK
Practice Address - State:FL
Practice Address - Zip Code:33023-3437
Practice Address - Country:US
Practice Address - Phone:786-230-7779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 310400000X
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility