Provider Demographics
NPI:1902419211
Name:MARTINEZ BALMASEDA, IDALYS
Entity Type:Individual
Prefix:
First Name:IDALYS
Middle Name:
Last Name:MARTINEZ BALMASEDA
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 1:15522 SW 60TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15522 SW 60TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-2804
Practice Address - Country:US
Practice Address - Phone:786-975-4017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty