Provider Demographics
NPI:1801604608
Name:MARTINEZ RODRIGUEZ, LISANDRA
Entity type:Individual
Prefix:
First Name:LISANDRA
Middle Name:
Last Name:MARTINEZ RODRIGUEZ
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 1:5741 NW 101ST WAY
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-2591
Mailing Address - Country:US
Mailing Address - Phone:954-248-9115
Mailing Address - Fax:
Practice Address - Street 1:1457 LAKE CRYSTAL DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-2017
Practice Address - Country:US
Practice Address - Phone:954-248-9115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-26
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-388536106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty