Provider Demographics
NPI:1831756196
Name:MARTINEZ IZQUIERDO, MARIELYS (BCABA)
Entity type:Individual
Prefix:MS
First Name:MARIELYS
Middle Name:
Last Name:MARTINEZ IZQUIERDO
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5647 SYCAMORE CANYON DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34758-1727
Mailing Address - Country:US
Mailing Address - Phone:786-616-3573
Mailing Address - Fax:
Practice Address - Street 1:897 TOWNE CENTER DR STE 101
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34759-3473
Practice Address - Country:US
Practice Address - Phone:786-616-3573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT1856653106S00000X
FL222Q00000X
FLSZ11176235Z00000X
FL0-20-10845106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0-20-10845OtherBOARD CERTIFIED ASSISTANT BEHAVIOR ANALYST
FLSZ11176OtherSPEECH LANGUAGE PATHOLOGIST