Provider Demographics
NPI:1912537754
Name:MARINO, LEIDY ESTHER
Entity Type:Individual
Prefix:
First Name:LEIDY
Middle Name:ESTHER
Last Name:MARINO
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 1:22416 SW 89TH PATH
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33190-1336
Mailing Address - Country:US
Mailing Address - Phone:786-278-0749
Mailing Address - Fax:
Practice Address - Street 1:2615 FAIRWAYS DR
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33035-1173
Practice Address - Country:US
Practice Address - Phone:786-426-3686
Practice Address - Fax:305-508-6697
Is Sole Proprietor?:No
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-101895106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician