Provider Demographics
NPI:1922691906
Name:CORRAL MARZO, CARLOS MANUEL
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:MANUEL
Last Name:CORRAL MARZO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:796 ILENE RD W
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33415-3758
Mailing Address - Country:US
Mailing Address - Phone:308-383-4930
Mailing Address - Fax:
Practice Address - Street 1:6415 LAKE WORTH RD STE 204
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-2904
Practice Address - Country:US
Practice Address - Phone:561-771-9561
Practice Address - Fax:800-766-3139
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-152829106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109618900Medicaid