Provider Demographics
NPI:1033993209
Name:MARTINEZ ILLAS, ERICK (RBT 23-291663)
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:
Last Name:MARTINEZ ILLAS
Suffix:
Gender:M
Credentials:RBT 23-291663
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17630 SW 112TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-5006
Mailing Address - Country:US
Mailing Address - Phone:786-776-7549
Mailing Address - Fax:
Practice Address - Street 1:17630 SW 112TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-5006
Practice Address - Country:US
Practice Address - Phone:786-776-7549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-291663106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician