Provider Demographics
NPI:1548314578
Name:TALARICO DE NOLASCO, MARIANA (PT)
Entity type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:TALARICO DE NOLASCO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3670 N 54TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-2340
Mailing Address - Country:US
Mailing Address - Phone:305-651-9311
Mailing Address - Fax:754-201-1390
Practice Address - Street 1:3670 N 54TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-2340
Practice Address - Country:US
Practice Address - Phone:305-651-9311
Practice Address - Fax:754-201-1390
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLPT 21718225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891721300Medicaid