Provider Demographics
NPI:1215635974
Name:MARTINEZ, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:MARTINEZ
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 1:10477 SW 108TH AVE UNIT E278
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-8158
Mailing Address - Country:US
Mailing Address - Phone:305-283-7789
Mailing Address - Fax:
Practice Address - Street 1:10477 SW 108TH AVE UNIT E278
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-8158
Practice Address - Country:US
Practice Address - Phone:305-283-7789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-247102106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician