Healthcare Provider Details

I. General information

NPI: 1972357556
Provider Name (Legal Business Name): MARIANA CHACON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2024
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W MCNAB RD # 255
POMPANO BEACH FL
33069-4719
US

IV. Provider business mailing address

801 MIDDLE ST
FT LAUDERDALE FL
33312-7109
US

V. Phone/Fax

Practice location:
  • Phone: 954-271-0035
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH24414
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: