Provider Demographics
NPI:1376732594
Name:TETRICK, MARTINA (LMHC)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:
Last Name:TETRICK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:MARTINA
Other - Middle Name:
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:1223 LAKE HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-2601
Mailing Address - Country:US
Mailing Address - Phone:407-929-6821
Mailing Address - Fax:407-898-2805
Practice Address - Street 1:2020 E ROBINSON ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-6045
Practice Address - Country:US
Practice Address - Phone:407-929-6821
Practice Address - Fax:407-898-2805
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7529101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL768765600Medicaid