Healthcare Provider Details

I. General information

NPI: 1023735305
Provider Name (Legal Business Name): MINEDITH MARENGO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 BUDINGER AVE
SAINT CLOUD FL
34769-7203
US

IV. Provider business mailing address

689 CORNERSTONE DR UNIT 102
KISSIMMEE FL
34744-6116
US

V. Phone/Fax

Practice location:
  • Phone: 407-910-2941
  • Fax:
Mailing address:
  • Phone: 863-419-6752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: