Provider Demographics
NPI:1437836731
Name:BOTANA MARTELL, GERENNY
Entity Type:Individual
Prefix:
First Name:GERENNY
Middle Name:
Last Name:BOTANA MARTELL
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 1:2854 SW 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3812
Mailing Address - Country:US
Mailing Address - Phone:305-772-3956
Mailing Address - Fax:
Practice Address - Street 1:12905 SW 42ND ST STE 113
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-2910
Practice Address - Country:US
Practice Address - Phone:786-953-4446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-281175106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician