Provider Demographics
NPI:1730605361
Name:MARTIN ESCALONA, JAVIER
Entity type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:MARTIN ESCALONA
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 1:15106 GLENMOOR DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-2811
Mailing Address - Country:US
Mailing Address - Phone:561-460-5253
Mailing Address - Fax:
Practice Address - Street 1:6801 LAKE WORTH RD STE 322
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33467-2966
Practice Address - Country:US
Practice Address - Phone:561-771-9561
Practice Address - Fax:800-766-3139
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-42248103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22024900Medicaid