Provider Demographics
NPI:1619415536
Name:THELUSMA, MARNEL
Entity Type:Individual
Prefix:
First Name:MARNEL
Middle Name:
Last Name:THELUSMA
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:PO BOX 268175
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-8175
Mailing Address - Country:US
Mailing Address - Phone:954-226-2812
Mailing Address - Fax:
Practice Address - Street 1:18690 NW 2ND AVE
Practice Address - Street 2:100
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-4508
Practice Address - Country:US
Practice Address - Phone:754-423-9194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-11
Last Update Date:2017-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker