Provider Demographics
NPI:1053110650
Name:PEREZ LOPEZ, ILEANA
Entity type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:PEREZ LOPEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2902 W WILDER AVE APT 38B
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-6758
Mailing Address - Country:US
Mailing Address - Phone:813-412-9896
Mailing Address - Fax:
Practice Address - Street 1:2902 W WILDER AVE APT 38B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-6758
Practice Address - Country:US
Practice Address - Phone:813-412-9896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1233101103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst