Provider Demographics
NPI:1003555186
Name:GUILLEN, MARIELL ANDREA
Entity Type:Individual
Prefix:
First Name:MARIELL
Middle Name:ANDREA
Last Name:GUILLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 CAPRI LN APT 3808
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-4023
Mailing Address - Country:US
Mailing Address - Phone:832-480-9953
Mailing Address - Fax:
Practice Address - Street 1:701 PROMENADE DR STE 250
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-6035
Practice Address - Country:US
Practice Address - Phone:954-399-2637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-216616106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician