Provider Demographics
NPI:1669123634
Name:MARQUEZ CASANOVA, TAMARA
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:MARQUEZ CASANOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TAMARA
Other - Middle Name:
Other - Last Name:MARQUEZ CASANOVA
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:100 ANDROS ST
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-7112
Mailing Address - Country:US
Mailing Address - Phone:786-606-0798
Mailing Address - Fax:
Practice Address - Street 1:100 ANDROS ST
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-7112
Practice Address - Country:US
Practice Address - Phone:786-606-0798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-126489106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112200700Medicaid