Basic Information
| Provider Information | |||||||||
| NPI: | 1750709416 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEREZ EBRAHIMI | ||||||||
| FirstName: | CONCEPCION | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4740 N STATE ROAD 7 | ||||||||
| Address2: | 201 | ||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333195839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544864005 | ||||||||
| FaxNumber: | 9544973857 | ||||||||
| Practice Location | |||||||||
| Address1: | 546 NW UNIVERSITY BLVD | ||||||||
| Address2: | SUITE202 | ||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349862286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723616767 | ||||||||
| FaxNumber: | 9544973857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2014 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.