Provider Demographics
NPI:1326570144
Name:RICLAIR, MARIE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:RICLAIR
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 1:4575 SE DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-6826
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10779 CAMBAY CIR
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3219
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 247200000X
FLRBT-18-73702106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019268200Medicaid