Provider Demographics
NPI:1083125934
Name:MARRERO, WANDALIZ
Entity Type:Individual
Prefix:
First Name:WANDALIZ
Middle Name:
Last Name:MARRERO
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 1:4698 MARINER BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-1945
Mailing Address - Country:US
Mailing Address - Phone:484-258-4553
Mailing Address - Fax:
Practice Address - Street 1:5535 GRAND BLVD STE A
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-3843
Practice Address - Country:US
Practice Address - Phone:352-269-5598
Practice Address - Fax:813-618-5022
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMH20078101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health