Provider Demographics
NPI:1518384007
Name:MARTENS, COLLEEN
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MARTENS
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 1:3601 BIRCHIN LANE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-8046
Mailing Address - Country:US
Mailing Address - Phone:239-900-0573
Mailing Address - Fax:
Practice Address - Street 1:6361 PRESIDENTIAL CT STE 101
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3583
Practice Address - Country:US
Practice Address - Phone:941-322-7027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW126071041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021489800Medicaid