Basic Information
Provider Information | |||||||||
NPI: | 1366972242 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARCANO | ||||||||
FirstName: | EVA | ||||||||
MiddleName: | NYDIA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MCAP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13534 LITTLE PARK DR APT 101 | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336183419 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8133899048 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8800 49TH ST N STE 106 | ||||||||
Address2: |   | ||||||||
City: | PINELLAS PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 337825332 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7275440044 | ||||||||
FaxNumber: | 7275450125 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2017 | ||||||||
LastUpdateDate: | 07/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.