Provider Demographics
NPI:1326873431
Name:HECTOR BACALLAO, MARISEL
Entity type:Individual
Prefix:
First Name:MARISEL
Middle Name:
Last Name:HECTOR BACALLAO
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 1:2600 NE 1ST LN APT 202
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-1941
Mailing Address - Country:US
Mailing Address - Phone:561-970-0208
Mailing Address - Fax:
Practice Address - Street 1:2600 NE 1ST LN APT 202
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-1941
Practice Address - Country:US
Practice Address - Phone:561-818-6554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-359005106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician