Provider Demographics
NPI:1073285854
Name:RODRIGUEZ FONSECA, MARIELYS
Entity Type:Individual
Prefix:
First Name:MARIELYS
Middle Name:
Last Name:RODRIGUEZ FONSECA
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 1:247 CORALWOOD CT
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-8353
Mailing Address - Country:US
Mailing Address - Phone:407-218-1583
Mailing Address - Fax:
Practice Address - Street 1:2151 CONSULATE DR STE 11
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-8806
Practice Address - Country:US
Practice Address - Phone:386-362-3926
Practice Address - Fax:407-641-9591
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109002400Medicaid