Provider Demographics
NPI:1063156651
Name:VEDOVA, MARNI LIANE
Entity type:Individual
Prefix:
First Name:MARNI
Middle Name:LIANE
Last Name:VEDOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 CECIL G COSTIN SR BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-1754
Mailing Address - Country:US
Mailing Address - Phone:850-227-1163
Mailing Address - Fax:
Practice Address - Street 1:528 CECIL G COSTIN SR BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1754
Practice Address - Country:US
Practice Address - Phone:850-227-1163
Practice Address - Fax:850-227-1137
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-207227106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician