Provider Demographics
NPI:1093565277
Name:FERNANDEZ MARTIN, MARLON
Entity Type:Individual
Prefix:
First Name:MARLON
Middle Name:
Last Name:FERNANDEZ MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 NW 170TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-4328
Mailing Address - Country:US
Mailing Address - Phone:786-201-4640
Mailing Address - Fax:
Practice Address - Street 1:4301 NW 170TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-4328
Practice Address - Country:US
Practice Address - Phone:786-201-4640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-334366106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty