Provider Demographics
NPI:1457979270
Name:PENA CHERICIAN, MARCO AURELIO
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:AURELIO
Last Name:PENA CHERICIAN
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 1:6256 SW 136TH CT APT E107
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-5037
Mailing Address - Country:US
Mailing Address - Phone:305-240-8274
Mailing Address - Fax:
Practice Address - Street 1:6256 SW 136TH CT APT E107
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-5037
Practice Address - Country:US
Practice Address - Phone:305-240-8274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-119477106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20-119477OtherBACB