Healthcare Provider Details

I. General information

NPI: 1548043417
Provider Name (Legal Business Name): ELIDETH VAZQUEZ MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

METRO PARK 7, STREET #1 SUITE 204
GUAYNABO PR
00968
US

IV. Provider business mailing address

4620 N STATE ROAD 7 STE 300
LAUDERDALE LAKES FL
33319-5867
US

V. Phone/Fax

Practice location:
  • Phone: 877-760-0222
  • Fax:
Mailing address:
  • Phone: 561-323-6593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: