Provider Demographics
NPI:1659985703
Name:MARCELLUS, IDALIE (CERTIFICATE)
Entity Type:Individual
Prefix:
First Name:IDALIE
Middle Name:
Last Name:MARCELLUS
Suffix:
Gender:F
Credentials:CERTIFICATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 NE 116TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-6622
Mailing Address - Country:US
Mailing Address - Phone:786-665-0518
Mailing Address - Fax:
Practice Address - Street 1:2904 NW 48TH ST
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33309-3510
Practice Address - Country:US
Practice Address - Phone:786-665-0518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-05
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM624-400-86-507-0251C00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251C00000XAgenciesDay Training, Developmentally Disabled Services