Healthcare Provider Details

I. General information

NPI: 1831500727
Provider Name (Legal Business Name): TAMARA L MARTIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2653 SW 87TH DR SUITE A
GAINESVILLE FL
32608-9313
US

IV. Provider business mailing address

2653 SW 87TH DR SUITE A
GAINESVILLE FL
32608-9313
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-0020
  • Fax: 352-331-0022
Mailing address:
  • Phone: 352-331-0020
  • Fax: 352-331-0022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY5599
License Number StateFL

VIII. Authorized Official

Name: TAMARA L MARTIN
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 352-331-0020