Provider Demographics
NPI:1740885953
Name:MAURO, VINCENT
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:
Last Name:MAURO
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 1:428 DOVE LN
Mailing Address - Street 2:
Mailing Address - City:SATELLITE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-3747
Mailing Address - Country:US
Mailing Address - Phone:845-570-0426
Mailing Address - Fax:
Practice Address - Street 1:111 W MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4130
Practice Address - Country:US
Practice Address - Phone:407-215-0095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNAMedicaid