Healthcare Provider Details

I. General information

NPI: 1104759091
Provider Name (Legal Business Name): MR. MATTHEW MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 S HIAWASSEE RD STE 101
ORLANDO FL
32835-5706
US

IV. Provider business mailing address

1507 S HIAWASSEE RD STE 101
ORLANDO FL
32835-5706
US

V. Phone/Fax

Practice location:
  • Phone: 407-248-0030
  • Fax:
Mailing address:
  • Phone: 407-248-0030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH13278
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: