Provider Demographics
NPI:1164907747
Name:GARCIA-MARTINEZ, WIDALYS
Entity Type:Individual
Prefix:
First Name:WIDALYS
Middle Name:
Last Name:GARCIA-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 1:7667 N WICKHAM RD
Mailing Address - Street 2:APT # 1205
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940
Mailing Address - Country:US
Mailing Address - Phone:787-617-2969
Mailing Address - Fax:
Practice Address - Street 1:1107 MABBETTE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5161
Practice Address - Country:US
Practice Address - Phone:407-201-8079
Practice Address - Fax:407-343-9180
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8545235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8545OtherDEPARTMENT OF HEALTH- DIVISION OF MEDICAL QUALITY ASSURANCE