Provider Demographics
NPI:1114990397
Name:DERITA, MARTIN A (LCSW, BCD)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:A
Last Name:DERITA
Suffix:
Gender:M
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 S MAITLAND AVE
Mailing Address - Street 2:SUITE101
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5677
Mailing Address - Country:US
Mailing Address - Phone:407-644-2121
Mailing Address - Fax:407-644-2974
Practice Address - Street 1:235 S MAITLAND AVE
Practice Address - Street 2:SUITE101
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5677
Practice Address - Country:US
Practice Address - Phone:407-644-2121
Practice Address - Fax:407-644-2974
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ2665BMedicare ID - Type Unspecified