Basic Information
| Provider Information | |||||||||
| NPI: | 1609114347 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAMAYO-MARRERO | ||||||||
| FirstName: | MIRZA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1675 PALM BEACH LAKES BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334012122 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1675 PALM BEACH LAKES BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334012122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618812822 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2013 | ||||||||
| LastUpdateDate: | 01/30/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | FL | Y | Behavioral Health & Social Service Providers | Social Worker | 222Q00000X | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | FL | MEDICAID |