Provider Demographics
NPI:1821412230
Name:AYALA-ICAZA, MARLY (MH14786)
Entity Type:Individual
Prefix:
First Name:MARLY
Middle Name:
Last Name:AYALA-ICAZA
Suffix:
Gender:F
Credentials:MH14786
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 EL CONQUISTADOR PKWY APT 259
Mailing Address - Street 2:APT 259
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-3819
Mailing Address - Country:US
Mailing Address - Phone:954-806-3698
Mailing Address - Fax:
Practice Address - Street 1:3500 EL CONQUISTADOR PKWY APT 259
Practice Address - Street 2:APT 259
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3819
Practice Address - Country:US
Practice Address - Phone:954-806-3698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-06
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH2387101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health