Provider Demographics
NPI:1548918337
Name:JUAREZ HERNANDEZ, MARTHA I
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:I
Last Name:JUAREZ HERNANDEZ
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 1:2744 EAGLE GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-3150
Mailing Address - Country:US
Mailing Address - Phone:321-402-8589
Mailing Address - Fax:
Practice Address - Street 1:222 BROADWAY UNIT 211
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5760
Practice Address - Country:US
Practice Address - Phone:407-329-3464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty