=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548073315
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIELINA DE LA CRUZ GARLOBO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2025
-----------------------------------------------------
Last Update Date | 01/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 SE PORT ST LUCIE BLVD STE 3
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34984-5108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-202-0173
-----------------------------------------------------
Fax | 772-209-7631
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4565 SW FLORAL ST
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34953-7622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-244-5389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-24-362305
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------