Provider Demographics
NPI:1366903239
Name:ROMERO, MAREL
Entity type:Individual
Prefix:
First Name:MAREL
Middle Name:
Last Name:ROMERO
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 1:9015 MURRAY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-3675
Mailing Address - Country:US
Mailing Address - Phone:408-842-7138
Mailing Address - Fax:
Practice Address - Street 1:9015 MURRAY AVE STE 100
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-3675
Practice Address - Country:US
Practice Address - Phone:408-842-7138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2023-08-28
Deactivation Date:2020-03-08
Deactivation Code:
Reactivation Date:2020-03-18
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
171M00000X, 390200000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician