MEDICARE: MARTINA CORDERO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1114568060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTINA CORDERO

Provider Business Mailing Address
First Line	:	13858 WATERTHRUSH PL
Second Line	:
City	:	LAKEWOOD RANCH
State	:	FL
Zip	:	34202-6345
Country	:	US
Telephone Number	:	870-283-4619
Fax Number	:

Provider Business Practice Location Address
First Line	:	8245 VICELA DR
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34240-1462
Country	:	US
Telephone Number	:	800-217-9289
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2019
Last Update Date	:	10/02/2019

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Directions to “ MARTINA CORDERO ” Practice Location

Language	Start Address	Practice Location

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