Provider Demographics
NPI:1962962019
Name:MARTIN, VICTORIA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:MARTIN
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 1:11536 SW 54TH ST
Mailing Address - Street 2:
Mailing Address - City:COOPER CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33330-4223
Mailing Address - Country:US
Mailing Address - Phone:954-257-0955
Mailing Address - Fax:
Practice Address - Street 1:11536 SW 54TH ST
Practice Address - Street 2:
Practice Address - City:COOPER CITY
Practice Address - State:FL
Practice Address - Zip Code:33330-4223
Practice Address - Country:US
Practice Address - Phone:954-257-0955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-24
Last Update Date:2019-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst