Provider Demographics
NPI:1912494089
Name:MEKDASHI, MARWA
Entity type:Individual
Prefix:
First Name:MARWA
Middle Name:
Last Name:MEKDASHI
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 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:672-785-5832
Mailing Address - Fax:
Practice Address - Street 1:4389 NE 343 HIGHWAY
Practice Address - Street 2:
Practice Address - City:OLD TOWN
Practice Address - State:FL
Practice Address - Zip Code:32680-7462
Practice Address - Country:US
Practice Address - Phone:672-785-5832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-15
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL12041665103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSMedicaid