Basic Information
| Provider Information | |||||||||
| NPI: | 1114172202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LA O | ||||||||
| FirstName: | MARIELIS | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15136 SW 63RD TER | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331932052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862532434 | ||||||||
| FaxNumber: | 3057574465 | ||||||||
| Practice Location | |||||||||
| Address1: | 15136 SW 63RD | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331932052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862532434 | ||||||||
| FaxNumber: | 3056431345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2008 | ||||||||
| LastUpdateDate: | 06/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | FL | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 106E00000X | FL | N | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 017915400 | 05 | FL | MEDICAID |