Healthcare Provider Details

I. General information

NPI: 1871080580
Provider Name (Legal Business Name): MARIELA PETRAKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 SW GLORIANA ST
PORT SAINT LUCIE FL
34987-4706
US

IV. Provider business mailing address

10701 SW GLORIANA ST
PORT SAINT LUCIE FL
34987-4706
US

V. Phone/Fax

Practice location:
  • Phone: 305-709-8974
  • Fax:
Mailing address:
  • Phone: 305-709-8974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-56186
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-20-11301
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: