Provider Demographics
NPI:1528673613
Name:VIDAL MARRERO, MARK STEVEN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:VIDAL MARRERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 TAMIAMI TRL N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-2853
Mailing Address - Country:US
Mailing Address - Phone:239-351-0675
Mailing Address - Fax:
Practice Address - Street 1:5050 TAMIAMI TRL N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-2853
Practice Address - Country:US
Practice Address - Phone:239-351-0675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-135484106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician