Provider Demographics
NPI:1326524117
Name:JIMENEZ MUSTELIER, MARIENE (ITDS)
Entity Type:Individual
Prefix:
First Name:MARIENE
Middle Name:
Last Name:JIMENEZ MUSTELIER
Suffix:
Gender:F
Credentials:ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SW PRIMA VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1967
Mailing Address - Country:US
Mailing Address - Phone:786-482-3369
Mailing Address - Fax:
Practice Address - Street 1:300 SW PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1967
Practice Address - Country:US
Practice Address - Phone:786-534-7127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-14
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLRBT-19-80416106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist