Healthcare Provider Details

I. General information

NPI: 1760399190
Provider Name (Legal Business Name): MARIANA ANGEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 DEVERS ST STE 101
FAYETTEVILLE NC
28303-4753
US

IV. Provider business mailing address

345 DEVERS ST STE 101
FAYETTEVILLE NC
28303-4753
US

V. Phone/Fax

Practice location:
  • Phone: 631-374-9604
  • Fax:
Mailing address:
  • Phone: 631-374-9604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-517256
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: