Provider Demographics
NPI:1073130217
Name:PAULA, MARITZA
Entity Type:Individual
Prefix:
First Name:MARITZA
Middle Name:
Last Name:PAULA
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 1:575 LIVE OAK AVE W APT 7303
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-5099
Mailing Address - Country:US
Mailing Address - Phone:939-630-7179
Mailing Address - Fax:
Practice Address - Street 1:164 OXFORD RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33896-8891
Practice Address - Country:US
Practice Address - Phone:939-630-7179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-04
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4415101YP2500X
FL104100000X, 251B00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty