Provider Demographics
NPI:1366155228
Name:GUNTER, MIA MARIE EBONY
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:MARIE EBONY
Last Name:GUNTER
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 1:825 MCCULLOUGH AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-7202
Mailing Address - Country:US
Mailing Address - Phone:352-445-5966
Mailing Address - Fax:
Practice Address - Street 1:825 MCCULLOUGH AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-7202
Practice Address - Country:US
Practice Address - Phone:352-445-5966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator