Provider Demographics
NPI:1285941690
Name:EZETA, MIRELLA CARLA (PSYD)
Entity type:Individual
Prefix:MS
First Name:MIRELLA
Middle Name:CARLA
Last Name:EZETA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3521 W BROWARD BLVD
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1048
Mailing Address - Country:US
Mailing Address - Phone:954-587-1008
Mailing Address - Fax:954-587-0080
Practice Address - Street 1:3521 W BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1048
Practice Address - Country:US
Practice Address - Phone:954-587-1008
Practice Address - Fax:954-587-0080
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9210101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health