Provider Demographics
NPI:1427580422
Name:PINO, MARIELA
Entity Type:Individual
Prefix:
First Name:MARIELA
Middle Name:
Last Name:PINO
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 1:6501 COW PEN RD APT D101
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-6627
Mailing Address - Country:US
Mailing Address - Phone:407-271-3807
Mailing Address - Fax:
Practice Address - Street 1:6501 COW PEN RD APT D101
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-6627
Practice Address - Country:US
Practice Address - Phone:407-271-3807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-53311103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104052200Medicaid