Healthcare Provider Details

I. General information

NPI: 1205003720
Provider Name (Legal Business Name): DEVA MARTINEZ EDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 BLOOMINGDALE OAKS DR
VALRICO FL
33596-6132
US

IV. Provider business mailing address

3405 BLOOMINGDALE OAKS DR
VALRICO FL
33596-6132
US

V. Phone/Fax

Practice location:
  • Phone: 870-476-3437
  • Fax:
Mailing address:
  • Phone: 870-476-3437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1403
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP1103014
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number14152
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH15370
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: