Provider Demographics
NPI:1225544604
Name:I ROCK BEHAVIOR LLC
Entity Type:Organization
Organization Name:I ROCK BEHAVIOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MALENA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS, BCBA
Authorized Official - Phone:786-376-5812
Mailing Address - Street 1:18480 NW 19TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-3823
Mailing Address - Country:US
Mailing Address - Phone:786-376-5812
Mailing Address - Fax:
Practice Address - Street 1:18480 NW 19TH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-3823
Practice Address - Country:US
Practice Address - Phone:786-376-5812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL662050Medicaid