Provider Demographics
NPI:1558971762
Name:BRACKE, MARIBEL DELIA (CTRS, CDP)
Entity Type:Individual
Prefix:MRS
First Name:MARIBEL
Middle Name:DELIA
Last Name:BRACKE
Suffix:
Gender:F
Credentials:CTRS, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16781 NW 167TH DR
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-6498
Mailing Address - Country:US
Mailing Address - Phone:224-223-3885
Mailing Address - Fax:
Practice Address - Street 1:1601 SW ARCHER RD # 117C
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1135
Practice Address - Country:US
Practice Address - Phone:352-376-1611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL63348225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Single Specialty