Provider Demographics
NPI:1093974487
Name:MARTINEZ, MARLEN (BS)
Entity Type:Individual
Prefix:MRS
First Name:MARLEN
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4630 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34235-1843
Mailing Address - Country:US
Mailing Address - Phone:941-487-5400
Mailing Address - Fax:941-487-5430
Practice Address - Street 1:4630 17TH ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34235-1843
Practice Address - Country:US
Practice Address - Phone:941-487-5400
Practice Address - Fax:941-487-5430
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL811630000Medicaid
FL810159101Medicaid