Provider Demographics
NPI:1356864912
Name:MARTINEZ RODRIGUEZ, MIRVYS
Entity Type:Individual
Prefix:
First Name:MIRVYS
Middle Name:
Last Name:MARTINEZ RODRIGUEZ
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 1:5599 NW 5TH ST APT C32
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26790 SW 142ND AVE APT 207
Practice Address - Street 2:
Practice Address - City:NARANJA
Practice Address - State:FL
Practice Address - Zip Code:33032-5427
Practice Address - Country:US
Practice Address - Phone:786-612-1796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-80459106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid