Provider Demographics
NPI:1134843584
Name:BARBOZA BRAVO, MARIOSCA
Entity type:Individual
Prefix:
First Name:MARIOSCA
Middle Name:
Last Name:BARBOZA BRAVO
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 1:16506 SW 9TH LANE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33194
Mailing Address - Country:US
Mailing Address - Phone:786-332-0041
Mailing Address - Fax:
Practice Address - Street 1:5220 S UNIVERSITY DR STE 204C
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-5308
Practice Address - Country:US
Practice Address - Phone:954-906-5947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCMS.0102554171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCBHCMS.0102554OtherFL CERTIFICATION BOARD