Provider Demographics
NPI:1689181109
Name:CASIDO, MARY LAURA I (BA)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:LAURA
Last Name:CASIDO
Suffix:I
Gender:F
Credentials:BA
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:LAURA
Other - Last Name:CASIDO
Other - Suffix:I
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4523 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-5327
Mailing Address - Country:US
Mailing Address - Phone:786-546-1092
Mailing Address - Fax:
Practice Address - Street 1:4523 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-5327
Practice Address - Country:US
Practice Address - Phone:786-546-1092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022111500Medicaid