Provider Demographics
NPI:1720758931
Name:GUERRA PONCE, MARIALIS
Entity Type:Individual
Prefix:
First Name:MARIALIS
Middle Name:
Last Name:GUERRA PONCE
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 1:1005 NE 15TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-1507
Mailing Address - Country:US
Mailing Address - Phone:704-949-6310
Mailing Address - Fax:
Practice Address - Street 1:1005 NE 15TH PL
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-1507
Practice Address - Country:US
Practice Address - Phone:704-949-6310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-18
Last Update Date:2021-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-182804106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician