MEDICARE: WHITLEY MARTIN RBT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-18-64705

General Provider Information

NPI Number	:	1407338346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WHITLEY MARTIN RBT

Provider Business Mailing Address
First Line	:	300 INTERNATIONAL PKWY STE 200
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5028
Country	:	US
Telephone Number	:	866-610-0580
Fax Number	:	407-588-6294

Provider Business Practice Location Address
First Line	:	535 RIVERSTONE PKWY STE 101
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30114-2566
Country	:	US
Telephone Number	:	866-610-0580
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2018
Last Update Date	:	05/26/2021

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Directions to “ WHITLEY MARTIN RBT” Practice Location

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