Provider Demographics
NPI:1346606142
Name:CONSTANZO MOBLEY, INGRID JOSEFINA
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:JOSEFINA
Last Name:CONSTANZO MOBLEY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 ROSEWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-1358
Mailing Address - Country:US
Mailing Address - Phone:321-217-6010
Mailing Address - Fax:877-399-5578
Practice Address - Street 1:1200 N CENTRAL AVE STE 110
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4439
Practice Address - Country:US
Practice Address - Phone:407-530-5063
Practice Address - Fax:877-399-5578
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-08
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X, 222Q00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist