Provider Demographics
NPI:1093315954
Name:OLIVERA REY, MARELIS
Entity Type:Individual
Prefix:
First Name:MARELIS
Middle Name:
Last Name:OLIVERA REY
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 1:1095 W 68TH ST APT 25
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-5141
Mailing Address - Country:US
Mailing Address - Phone:786-366-3809
Mailing Address - Fax:
Practice Address - Street 1:1095 W 68TH ST APT 25
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-5141
Practice Address - Country:US
Practice Address - Phone:786-366-3809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-127664106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty