Provider Demographics
NPI:1982161279
Name:CHACON, MARIE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:CHACON
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 1:6280 NW 173RD ST APT 1235
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4566
Mailing Address - Country:US
Mailing Address - Phone:305-615-9297
Mailing Address - Fax:
Practice Address - Street 1:6280 NW 173RD ST APT 1235
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-4566
Practice Address - Country:US
Practice Address - Phone:305-615-9297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-22-13524106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBCABA-0-22-13524OtherBACB