Provider Demographics
NPI:1902517089
Name:ALFONSO ADAY, MARIVEL
Entity Type:Individual
Prefix:
First Name:MARIVEL
Middle Name:
Last Name:ALFONSO ADAY
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 1:6516 EATON ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-7653
Mailing Address - Country:US
Mailing Address - Phone:786-557-3413
Mailing Address - Fax:
Practice Address - Street 1:6516 EATON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-7653
Practice Address - Country:US
Practice Address - Phone:786-557-3413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLRBT-20-140038106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty