Provider Demographics
NPI:1477972008
Name:MERCIUS, ODLINE
Entity Type:Individual
Prefix:
First Name:ODLINE
Middle Name:
Last Name:MERCIUS
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 1:2529 GLACIER EXPRESS LN
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5178
Mailing Address - Country:US
Mailing Address - Phone:772-812-0518
Mailing Address - Fax:
Practice Address - Street 1:2529 GLACIER EXPRESS LN
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5178
Practice Address - Country:US
Practice Address - Phone:772-812-0518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2023-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-46498103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst