Provider Demographics
NPI:1568144178
Name:MARTINEZ, LAIS
Entity Type:Individual
Prefix:
First Name:LAIS
Middle Name:
Last Name:MARTINEZ
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 1:9061 SW 208TH TER
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-3887
Mailing Address - Country:US
Mailing Address - Phone:954-381-9344
Mailing Address - Fax:
Practice Address - Street 1:8180 NW 36TH ST STE 319
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6674
Practice Address - Country:US
Practice Address - Phone:786-652-1513
Practice Address - Fax:786-652-1543
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-255621106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician