Provider Demographics
NPI:1356880843
Name:CARO-CORTES, MIRELLA
Entity type:Individual
Prefix:
First Name:MIRELLA
Middle Name:
Last Name:CARO-CORTES
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 1:1035 LAKE ROGERS CIR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7225
Mailing Address - Country:US
Mailing Address - Phone:407-810-4471
Mailing Address - Fax:
Practice Address - Street 1:1950 W STATE ROAD 426
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9145
Practice Address - Country:US
Practice Address - Phone:407-803-4717
Practice Address - Fax:407-347-2293
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH13349101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021092600Medicaid