Provider Demographics
NPI:1396439212
Name:AVILA MARTINEZ, MARCO EUGENIO
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:EUGENIO
Last Name:AVILA MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14841 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-2833
Mailing Address - Country:US
Mailing Address - Phone:786-491-9102
Mailing Address - Fax:
Practice Address - Street 1:14841 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-2833
Practice Address - Country:US
Practice Address - Phone:786-491-9102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-267421106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-23-267421OtherBACB FLORIDA