Provider Demographics
NPI:1508109992
Name:MARTINEZ, CAROLYN ELIZABETH (BCBA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ELIZABETH
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3723 GURLEY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-2012
Mailing Address - Country:US
Mailing Address - Phone:904-445-9732
Mailing Address - Fax:
Practice Address - Street 1:3723 GURLEY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-2012
Practice Address - Country:US
Practice Address - Phone:904-445-9732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL080966796Medicaid