Provider Demographics
NPI:1376390609
Name:BERNAL DE TOVAR, MARIELA
Entity type:Individual
Prefix:
First Name:MARIELA
Middle Name:
Last Name:BERNAL DE TOVAR
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 1:946 SW 4TH ST APT 303
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-2264
Mailing Address - Country:US
Mailing Address - Phone:305-970-9645
Mailing Address - Fax:
Practice Address - Street 1:900 E 9TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-4650
Practice Address - Country:US
Practice Address - Phone:305-381-5294
Practice Address - Fax:786-685-2266
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-03
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
FL24-346726106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor