Provider Demographics
NPI:1063217156
Name:MARTIN, ANTWUAN DONNELL
Entity type:Individual
Prefix:MR
First Name:ANTWUAN
Middle Name:DONNELL
Last Name:MARTIN
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 1:10975 OSPREY GLADE TER
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-0405
Mailing Address - Country:US
Mailing Address - Phone:813-777-0899
Mailing Address - Fax:
Practice Address - Street 1:10975 OSPREY GLADE TER
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-0405
Practice Address - Country:US
Practice Address - Phone:813-777-0899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-13
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW242381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical