Healthcare Provider Details

I. General information

NPI: 1477415073
Provider Name (Legal Business Name): MARIELYS SURI TERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 VESPUCCI AVE S
LEHIGH ACRES FL
33974-4644
US

IV. Provider business mailing address

833 VESPUCCI AVE S
LEHIGH ACRES FL
33974-4644
US

V. Phone/Fax

Practice location:
  • Phone: 239-703-6969
  • Fax:
Mailing address:
  • Phone: 239-703-6969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-493282
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: