Basic Information
| Provider Information | |||||||||
| NPI: | 1568969426 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CERI | ||||||||
| FirstName: | PRISCILLA | ||||||||
| MiddleName: | HOPE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PABON | ||||||||
| OtherFirstName: | PRISCILLA | ||||||||
| OtherMiddleName: | HOPE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 306 E OAK ST | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347444537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079338331 | ||||||||
| FaxNumber: | 4079449471 | ||||||||
| Practice Location | |||||||||
| Address1: | 306 E OAK ST | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347444537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079338331 | ||||||||
| FaxNumber: | 4079449471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2018 | ||||||||
| LastUpdateDate: | 04/09/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 101YA0400X | 05 | FL | MEDICAID |