=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366507980
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLENDA MARTINEZ PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2006
-----------------------------------------------------
Last Update Date | 11/29/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1435 W 49TH PL PALM SPRINGS MEDICAL PLAZA, SUITE 304
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-3197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-557-6755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8545 NW 140TH ST APT 1104
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33016-6712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-308-6881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 7415
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------