Provider Demographics
NPI:1609362086
Name:MERCEDES, INGRID L
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:L
Last Name:MERCEDES
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 1:920 HUNTERS CREEK DR APT 5303
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-0978
Mailing Address - Country:US
Mailing Address - Phone:561-800-6734
Mailing Address - Fax:
Practice Address - Street 1:920 HUNTERS CREEK DR APT 5303
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-0978
Practice Address - Country:US
Practice Address - Phone:561-800-6734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-56762106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020891800Medicaid