Provider Demographics
NPI:1619321080
Name:BARROSO CUE, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:BARROSO CUE
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6050
Mailing Address - Fax:239-343-6051
Practice Address - Street 1:15901 BASS RD STE 102
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3838
Practice Address - Country:US
Practice Address - Phone:239-343-6050
Practice Address - Fax:239-343-6051
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-21
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FLPY12463103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL124784500Medicaid