Provider Demographics
NPI:1376927012
Name:MERCADO, MONIQUE
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:MERCADO
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 1:1759 W BROADWAY ST
Mailing Address - Street 2:STE 3
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-8128
Mailing Address - Country:US
Mailing Address - Phone:407-977-4335
Mailing Address - Fax:407-977-4370
Practice Address - Street 1:1759 W BROADWAY ST
Practice Address - Street 2:STE 3
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8128
Practice Address - Country:US
Practice Address - Phone:407-977-4335
Practice Address - Fax:407-977-4370
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW129131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001522900Medicaid