Provider Demographics
NPI:1609459544
Name:MESA, MARLEN (RBT-19-94552)
Entity type:Individual
Prefix:MS
First Name:MARLEN
Middle Name:
Last Name:MESA
Suffix:
Gender:F
Credentials:RBT-19-94552
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4692 NW 107TH AVE APT 1410
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4254
Mailing Address - Country:US
Mailing Address - Phone:786-312-5268
Mailing Address - Fax:
Practice Address - Street 1:4692 NW 107TH AVE APT 1410
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-4254
Practice Address - Country:US
Practice Address - Phone:786-312-5268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-94552106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104930900Medicaid