Healthcare Provider Details

I. General information

NPI: 1720777295
Provider Name (Legal Business Name): MERCEDES MANUELA PALACIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 05/02/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3140 OLD CANOE CREEK RD
SAINT CLOUD FL
34772-7655
US

IV. Provider business mailing address

3140 OLD CANOE CREEK RD
SAINT CLOUD FL
34772-7655
US

V. Phone/Fax

Practice location:
  • Phone: 786-777-8247
  • Fax:
Mailing address:
  • Phone: 786-777-8247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB853349
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: