Provider Demographics
NPI:1114172202
Name:LA O, MARIELIS (BCBA)
Entity Type:Individual
Prefix:
First Name:MARIELIS
Middle Name:
Last Name:LA O
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15136 SW 63RD TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2052
Mailing Address - Country:US
Mailing Address - Phone:786-253-2434
Mailing Address - Fax:305-757-4465
Practice Address - Street 1:15136 SW 63RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-2052
Practice Address - Country:US
Practice Address - Phone:786-253-2434
Practice Address - Fax:305-643-1345
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X, 106E00000X
104100000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017915400Medicaid