Provider Demographics
NPI:1154866580
Name:MARTINEZ GUTIERREZ, MAIDELIS
Entity Type:Individual
Prefix:
First Name:MAIDELIS
Middle Name:
Last Name:MARTINEZ GUTIERREZ
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 1:2510 SW 81ST AVE
Mailing Address - Street 2:APT 208
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33324-5788
Mailing Address - Country:US
Mailing Address - Phone:786-326-9248
Mailing Address - Fax:305-901-1797
Practice Address - Street 1:2510 SW 81ST AVE
Practice Address - Street 2:APT 208
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324-5788
Practice Address - Country:US
Practice Address - Phone:786-326-9248
Practice Address - Fax:305-901-1797
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician