Provider Demographics
NPI:1104792894
Name:MERCADO LUCIANO, MARITZA
Entity type:Individual
Prefix:
First Name:MARITZA
Middle Name:
Last Name:MERCADO LUCIANO
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:K11 CALLE PUEBLO NUEVO
Mailing Address - Street 2:
Mailing Address - City:CABO ROJO
Mailing Address - State:PR
Mailing Address - Zip Code:00623-3407
Mailing Address - Country:US
Mailing Address - Phone:787-347-6998
Mailing Address - Fax:
Practice Address - Street 1:K11 CALLE PUEBLO NUEVO
Practice Address - Street 2:
Practice Address - City:CABO ROJO
Practice Address - State:PR
Practice Address - Zip Code:00623-3407
Practice Address - Country:US
Practice Address - Phone:787-347-6998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-11
Last Update Date:2025-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR779101200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101200000XBehavioral Health & Social Service ProvidersDrama TherapistGroup - Single Specialty