Provider Demographics
NPI:1083248900
Name:MARTINEZ CARRILLO, LORIE
Entity Type:Individual
Prefix:
First Name:LORIE
Middle Name:
Last Name:MARTINEZ CARRILLO
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 1:5665 SW 5TH TER
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-1034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5665 SW 5TH TER
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-1034
Practice Address - Country:US
Practice Address - Phone:786-378-1889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-29
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-108014106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105709500Medicaid