Healthcare Provider Details

I. General information

NPI: 1366115925
Provider Name (Legal Business Name): IRIDIAN RAFAELA MARQUINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3775 VENTURE DR STE M101
DULUTH GA
30096-5217
US

IV. Provider business mailing address

187 GREEN BRIDGE CT
LAWRENCEVILLE GA
30046-9473
US

V. Phone/Fax

Practice location:
  • Phone: 470-610-4222
  • Fax:
Mailing address:
  • Phone: 770-771-2743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-87291
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB702046
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: