Provider Demographics
NPI:1104306091
Name:MAS MORE, MARTHA MARIA
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:MARIA
Last Name:MAS MORE
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 1:12021 SW 176TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-2348
Mailing Address - Country:US
Mailing Address - Phone:305-492-3138
Mailing Address - Fax:
Practice Address - Street 1:12021 SW 176TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-2348
Practice Address - Country:US
Practice Address - Phone:305-492-3138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-15-08012106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018900400Medicaid