Provider Demographics
NPI:1407462500
Name:FERNANDEZ, MARTHA
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-2430
Mailing Address - Country:US
Mailing Address - Phone:239-747-3873
Mailing Address - Fax:
Practice Address - Street 1:18245 PAULSON DR STE 104
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33954-1019
Practice Address - Country:US
Practice Address - Phone:813-528-7048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20132469106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician