Healthcare Provider Details

I. General information

NPI: 1457048852
Provider Name (Legal Business Name): SUSANA COLUMBIE MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 JEREMIAH WAY
KISSIMMEE FL
34743-3718
US

IV. Provider business mailing address

2112 JEREMIAH WAY
KISSIMMEE FL
34743-3718
US

V. Phone/Fax

Practice location:
  • Phone: 407-664-6551
  • Fax:
Mailing address:
  • Phone: 407-664-6551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-2841553
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-261091
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: