Provider Demographics
NPI:1720789548
Name:MARTINEZ GUTIERREZ, DIANELIS
Entity Type:Individual
Prefix:
First Name:DIANELIS
Middle Name:
Last Name:MARTINEZ GUTIERREZ
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 1:5641 FARRAGUT ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-2720
Mailing Address - Country:US
Mailing Address - Phone:786-873-6738
Mailing Address - Fax:
Practice Address - Street 1:5641 FARRAGUT ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-2720
Practice Address - Country:US
Practice Address - Phone:786-873-6738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-140527106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician