Provider Demographics
NPI: | 1124570916 |
---|---|
Name: | COLON MARQUEZ, LUIS |
Entity Type: | Individual |
Prefix: | |
First Name: | LUIS |
Middle Name: | |
Last Name: | COLON MARQUEZ |
Suffix: | |
Gender: | M |
Credentials: | |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 701 PETES LN |
Mailing Address - Street 2: | |
Mailing Address - City: | DAVENPORT |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33837-8762 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 787-464-2592 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 701 PETES LN |
Practice Address - Street 2: | |
Practice Address - City: | DAVENPORT |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33837-8762 |
Practice Address - Country: | US |
Practice Address - Phone: | 787-464-2592 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2016-10-27 |
Last Update Date: | 2023-07-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
101Y00000X | ||
FL | MH20962 | 101YM0800X |
FL | 0102603 | 104100000X |
FL | CBHCMS0102603 | 171M00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 171M00000X | Other Service Providers | Case Manager/Care Coordinator | |
No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker |