Provider Demographics
NPI:1962771931
Name:MARTIN, TINA MYREE (BS, QMHP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MYREE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:BS, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 VICTORY BLVD APT F
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23702-2668
Mailing Address - Country:US
Mailing Address - Phone:757-717-3456
Mailing Address - Fax:
Practice Address - Street 1:2708 NE 14TH ST APT 5
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-3564
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT62178724222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist