Provider Demographics
NPI:1932670312
Name:SAN PEDRO, MARCEL
Entity Type:Individual
Prefix:
First Name:MARCEL
Middle Name:
Last Name:SAN PEDRO
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 1:7425 SW 32ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-2726
Mailing Address - Country:US
Mailing Address - Phone:561-351-9349
Mailing Address - Fax:
Practice Address - Street 1:7425 SW 32ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-2726
Practice Address - Country:US
Practice Address - Phone:561-351-9349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16485101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health