Provider Demographics
NPI:1245848035
Name:MARTINEZ, MICHELLE ANA
Entity type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:ANA
Last Name:MARTINEZ
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 1:5560 W 21ST CT APT 109
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-7064
Mailing Address - Country:US
Mailing Address - Phone:786-340-9976
Mailing Address - Fax:
Practice Address - Street 1:144 NW 37TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33127-3111
Practice Address - Country:US
Practice Address - Phone:305-767-1924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-121785106S00000X
FLRBT-23-288211106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20-121785OtherRBT
FLRBT-23-288211OtherBACB RBT