Healthcare Provider Details

I. General information

NPI: 1205216710
Provider Name (Legal Business Name): ALYSSA MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 SE OCEAN BLVD STE B&C
STUART FL
34994-2456
US

IV. Provider business mailing address

523 PANTERTOWN CIR
MINERAL BLUFF GA
30559-2016
US

V. Phone/Fax

Practice location:
  • Phone: 772-872-6940
  • Fax:
Mailing address:
  • Phone: 772-800-8594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: