Provider Demographics
NPI:1932610250
Name:CASTRO LEYVA, MARIANA
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:CASTRO LEYVA
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 1:1595 NE 135TH ST APT 339
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-4476
Mailing Address - Country:US
Mailing Address - Phone:305-934-3719
Mailing Address - Fax:
Practice Address - Street 1:1595 NE 135TH ST APT 339
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-4476
Practice Address - Country:US
Practice Address - Phone:305-934-3719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-12
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102890200Medicaid