Provider Demographics
NPI:1629368618
Name:MINTEER, MARTHA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:MINTEER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 NW 83RD ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6227
Mailing Address - Country:US
Mailing Address - Phone:352-334-4060
Mailing Address - Fax:352-334-4059
Practice Address - Street 1:3303 NW 83RD ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6227
Practice Address - Country:US
Practice Address - Phone:352-334-4060
Practice Address - Fax:352-334-4059
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW9247101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001228000OtherMED WAIVER