Provider Demographics
NPI:1598398976
Name:CAPASSO, MARTINA M
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:M
Last Name:CAPASSO
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 1:6280 S EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-3233
Mailing Address - Country:US
Mailing Address - Phone:352-613-3633
Mailing Address - Fax:
Practice Address - Street 1:6280 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34446-3233
Practice Address - Country:US
Practice Address - Phone:352-613-3633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-111963106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician