Provider Demographics
NPI:1548953904
Name:MARTINEZ SANTIESTEBAN, TALIA
Entity type:Individual
Prefix:
First Name:TALIA
Middle Name:
Last Name:MARTINEZ SANTIESTEBAN
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 1:9404 WINDERMERE LAKE DR APT 201
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-3094
Mailing Address - Country:US
Mailing Address - Phone:813-696-8158
Mailing Address - Fax:
Practice Address - Street 1:9404 WINDERMERE LAKE DR APT 201
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-3094
Practice Address - Country:US
Practice Address - Phone:813-696-8158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-276539106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician