Provider Demographics
NPI:1144913518
Name:MARTINEZ MARTINEZ, MILDREY
Entity type:Individual
Prefix:MS
First Name:MILDREY
Middle Name:
Last Name:MARTINEZ 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 1:25916 SW 122ND PL
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-7062
Mailing Address - Country:US
Mailing Address - Phone:786-234-2022
Mailing Address - Fax:
Practice Address - Street 1:25916 SW 122ND PL
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-7062
Practice Address - Country:US
Practice Address - Phone:786-234-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-124075106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician