Provider Demographics
NPI:1952089260
Name:MARTINEZ, ANGEL LYNN
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:LYNN
Last Name:MARTINEZ
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 1:6031 SW 183RD WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTHWEST RANCHES
Mailing Address - State:FL
Mailing Address - Zip Code:33331-1637
Mailing Address - Country:US
Mailing Address - Phone:954-607-9019
Mailing Address - Fax:
Practice Address - Street 1:5400 S UNIVERSITY DR STE 203
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-5309
Practice Address - Country:US
Practice Address - Phone:954-513-9545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB855238106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician