Provider Demographics
NPI:1083285233
Name:TYRE-MARTINEZ, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:TYRE-MARTINEZ
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 1:2138 SANDRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-4486
Mailing Address - Country:US
Mailing Address - Phone:502-741-7660
Mailing Address - Fax:844-352-7445
Practice Address - Street 1:2138 SANDRIDGE CIR
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-4486
Practice Address - Country:US
Practice Address - Phone:502-741-7660
Practice Address - Fax:844-352-7445
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-169920106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician