Provider Demographics
NPI:1790465193
Name:MARTINEZ, MIKAYLA ROSE
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:ROSE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIKAYLA
Other - Middle Name:ROSE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7800 METRO PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1509
Mailing Address - Country:US
Mailing Address - Phone:651-322-0152
Mailing Address - Fax:
Practice Address - Street 1:7800 METRO PKWY STE 300
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1509
Practice Address - Country:US
Practice Address - Phone:651-322-0152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician