Healthcare Provider Details

I. General information

NPI: 1922761980
Provider Name (Legal Business Name): MARIELA VACA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 08/19/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 SW 15TH PL
CAPE CORAL FL
33991-2639
US

IV. Provider business mailing address

1112 SW 15TH PL
CAPE CORAL FL
33991-2639
US

V. Phone/Fax

Practice location:
  • Phone: 786-223-0934
  • Fax:
Mailing address:
  • Phone: 786-223-0934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-125248
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: