Provider Demographics
NPI:1447956974
Name:PUERTO, MARIANELA (CBHCM0104832)
Entity type:Individual
Prefix:
First Name:MARIANELA
Middle Name:
Last Name:PUERTO
Suffix:
Gender:F
Credentials:CBHCM0104832
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13525 SW 66TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-2372
Mailing Address - Country:US
Mailing Address - Phone:786-413-6085
Mailing Address - Fax:
Practice Address - Street 1:13525 SW 66TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-2372
Practice Address - Country:US
Practice Address - Phone:786-413-6085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0104832171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0104832OtherCBHCM