Provider Demographics
NPI:1083175343
Name:MARTIN, ALEXANDRA PATRICIA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:PATRICIA
Last Name:MARTIN
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 1:556 NW 208TH WAY
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-2154
Mailing Address - Country:US
Mailing Address - Phone:786-623-1347
Mailing Address - Fax:
Practice Address - Street 1:556 NW 208TH WAY
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-2154
Practice Address - Country:US
Practice Address - Phone:786-774-7729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-73984106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022869100Medicaid