Provider Demographics
NPI:1134599921
Name:BRACCIALE, MARIE (PHD , LMFT, CAP)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:
Last Name:BRACCIALE
Suffix:
Gender:F
Credentials:PHD , LMFT, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1518
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32170-1518
Mailing Address - Country:US
Mailing Address - Phone:386-383-4490
Mailing Address - Fax:386-506-0008
Practice Address - Street 1:600 ELIZABETH PL
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-2824
Practice Address - Country:US
Practice Address - Phone:386-322-6180
Practice Address - Fax:386-506-0008
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2517L CAP101YA0400X
FL481172 DOE101YS0200X
FLMT 1604106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL765941500Medicaid