Healthcare Provider Details

I. General information

NPI: 1164301206
Provider Name (Legal Business Name): JOANN MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 09/02/2025
Certification Date: 09/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 LOUISIANA AVE
SAINT CLOUD FL
34769-4116
US

IV. Provider business mailing address

1726 DELIGHTFUL DR
DAVENPORT FL
33896-7226
US

V. Phone/Fax

Practice location:
  • Phone: 407-593-0122
  • Fax: 407-593-0122
Mailing address:
  • Phone: 954-595-0560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCBHCMS.0102825
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: