Provider Demographics
NPI:1760071732
Name:MERCADO SOLIS, ROSA MARIA
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:MARIA
Last Name:MERCADO SOLIS
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 1:1400NW 79ST
Mailing Address - Street 2:F-608
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33147
Mailing Address - Country:US
Mailing Address - Phone:786-710-3769
Mailing Address - Fax:
Practice Address - Street 1:2400 NW 54TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-2946
Practice Address - Country:US
Practice Address - Phone:786-587-4524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-20-147954103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM623-733-80-803-0OtherDRIVER LICENSE