Provider Demographics
NPI:1710593991
Name:MARRERO, ODALIS DE LAS MERCEDES
Entity Type:Individual
Prefix:
First Name:ODALIS
Middle Name:DE LAS MERCEDES
Last Name:MARRERO
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 1:6502 BLUE RIBBON LN APT 301
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-2480
Mailing Address - Country:US
Mailing Address - Phone:786-675-9955
Mailing Address - Fax:
Practice Address - Street 1:341 E 35TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-2631
Practice Address - Country:US
Practice Address - Phone:786-675-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-133004106E00000X
RBT-20-133004106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst