Provider Demographics
NPI:1932857729
Name:SELLES MARTINEZ, ODELAYSI VIRGEN X (BACB670274)
Entity type:Individual
Prefix:
First Name:ODELAYSI
Middle Name:VIRGEN
Last Name:SELLES MARTINEZ
Suffix:X
Gender:F
Credentials:BACB670274
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:904-575-6451
Mailing Address - Fax:
Practice Address - Street 1:46 E 44TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-5308
Practice Address - Country:US
Practice Address - Phone:904-575-6451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2022-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21-169241106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21-169245OtherRBT