Provider Demographics
NPI:1497400261
Name:MERCADO, ANGEL (ITDS)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:MERCADO
Suffix:
Gender:M
Credentials:ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 NE 30TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLE GLADE
Mailing Address - State:FL
Mailing Address - Zip Code:33430-2363
Mailing Address - Country:US
Mailing Address - Phone:561-449-9183
Mailing Address - Fax:
Practice Address - Street 1:1116 NE 30TH ST
Practice Address - Street 2:
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-2363
Practice Address - Country:US
Practice Address - Phone:561-449-9183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-19
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty