Provider Demographics
NPI:1396562872
Name:MARTINEZ, GWEN STEPHANIE
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:STEPHANIE
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 1:11347 SW 5TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1165
Mailing Address - Country:US
Mailing Address - Phone:786-953-3222
Mailing Address - Fax:
Practice Address - Street 1:11347 SW 5TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1165
Practice Address - Country:US
Practice Address - Phone:786-953-3222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-354493106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician