Provider Demographics
NPI:1053651141
Name:MARTINEZ, DOMINIQUE FRANCES (BCBA)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:FRANCES
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 MICHIGAN AVE
Mailing Address - Street 2:UNIT A
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4860
Mailing Address - Country:US
Mailing Address - Phone:305-922-3818
Mailing Address - Fax:
Practice Address - Street 1:3730 GATLIN WOOD DRIVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-16-7071103K00000X
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program