Provider Demographics
NPI:1497163570
Name:MICCIO, MARIELA INES
Entity Type:Individual
Prefix:
First Name:MARIELA
Middle Name:INES
Last Name:MICCIO
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 1:6160 SW 195TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33332-3391
Mailing Address - Country:US
Mailing Address - Phone:786-348-6957
Mailing Address - Fax:
Practice Address - Street 1:6160 SW 195TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33332-3391
Practice Address - Country:US
Practice Address - Phone:786-348-6957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-01
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLOTA13468224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant