Provider Demographics
NPI:1760970321
Name:MARTIN, TIA TAJUANA
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:TAJUANA
Last Name:MARTIN
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 1:1723 ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-4374
Mailing Address - Country:US
Mailing Address - Phone:850-532-4749
Mailing Address - Fax:
Practice Address - Street 1:1723 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-4374
Practice Address - Country:US
Practice Address - Phone:850-532-4749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-28
Last Update Date:2018-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA197753103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid