Healthcare Provider Details

I. General information

NPI: 1376993956
Provider Name (Legal Business Name): MARIELA CUERVO PONCE RBT-15-10869
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 NW 4TH ST
MIAMI FL
33128-1609
US

IV. Provider business mailing address

405 NW 4TH ST
MIAMI FL
33128-1609
US

V. Phone/Fax

Practice location:
  • Phone: 786-357-2540
  • Fax:
Mailing address:
  • Phone: 786-357-2540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: