Provider Demographics
NPI:1104505122
Name:DEJESUS-MARTINEZ, KIARALIS
Entity type:Individual
Prefix:
First Name:KIARALIS
Middle Name:
Last Name:DEJESUS-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 1:721 NW 93RD TER
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6343
Mailing Address - Country:US
Mailing Address - Phone:305-542-2043
Mailing Address - Fax:305-542-2043
Practice Address - Street 1:18490 JOHNSON ST UNIT EFGH
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-3699
Practice Address - Country:US
Practice Address - Phone:754-264-8779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-284705106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician