Provider Demographics
NPI:1598808230
Name:MARQUEZ, MARTHA GRACE (LMHC, MCAP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:GRACE
Last Name:MARQUEZ
Suffix:
Gender:F
Credentials:LMHC, MCAP
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:MARQUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC, MCAP
Mailing Address - Street 1:1881 NE 26TH ST STE 201A
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1427
Mailing Address - Country:US
Mailing Address - Phone:954-368-5819
Mailing Address - Fax:954-530-1792
Practice Address - Street 1:1881 NE 26TH ST STE 201A
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305
Practice Address - Country:US
Practice Address - Phone:965-368-5819
Practice Address - Fax:954-530-1792
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8046101YM0800X, 101YP2500X
FLCAP4063101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076576700Medicaid