Healthcare Provider Details

I. General information

NPI: 1457720211
Provider Name (Legal Business Name): MARINA F ESPINOSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 09/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4898 E IRLO BRONSON MEMORIAL HWY
SAINT CLOUD FL
34771-8714
US

IV. Provider business mailing address

541 MICHIGAN STATES CL
SAINT CLOUD FL
34769
US

V. Phone/Fax

Practice location:
  • Phone: 407-891-1308
  • Fax:
Mailing address:
  • Phone: 407-346-0573
  • Fax: 855-479-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH13204
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: