Provider Demographics
NPI:1932843356
Name:MARTINEZ, MYNOR HUMBERTO
Entity Type:Individual
Prefix:MR
First Name:MYNOR
Middle Name:HUMBERTO
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18755 SW 351ST ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33034-4508
Mailing Address - Country:US
Mailing Address - Phone:786-261-7978
Mailing Address - Fax:
Practice Address - Street 1:18755 SW 351ST ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33034-4508
Practice Address - Country:US
Practice Address - Phone:786-261-7978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-210126106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty