Provider Demographics
NPI:1235983537
Name:MARTINEZ, LEIDIS
Entity Type:Individual
Prefix:
First Name:LEIDIS
Middle Name:
Last Name: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 1:3170 NW 96TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33147-2265
Mailing Address - Country:US
Mailing Address - Phone:305-458-6203
Mailing Address - Fax:
Practice Address - Street 1:7500 NW 25TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33122-1713
Practice Address - Country:US
Practice Address - Phone:305-909-4872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM635520908080106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician