Provider Demographics
NPI:1508371634
Name:MARTINE FENELON, PSYD, LLC
Entity Type:Organization
Organization Name:MARTINE FENELON, PSYD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:FENELON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:305-527-9964
Mailing Address - Street 1:160 NW 176TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5041
Mailing Address - Country:US
Mailing Address - Phone:305-249-2333
Mailing Address - Fax:
Practice Address - Street 1:160 NW 176TH ST STE 300
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-5041
Practice Address - Country:US
Practice Address - Phone:305-249-2333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP9127103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty