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NPI Code Detail

MEDICARE: DEATRA MARTIN

MEDICARE: DEATRA MARTIN
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
1106H00000XMarriage & Family TherapistIMT2454FL

General Provider Information

NPI Number : 1659926392
Entity Type Code : Individual
Provider Name (Legal Business Name) : DEATRA MARTIN
Provider Business Mailing Address
First Line : 9433 PEBBLE GLEN AVE
Second Line :
City : TAMPA
State : FL
Zip : 33647-2435
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 9433 PEBBLE GLEN AVE
Second Line :
City : TAMPA
State : FL
Zip : 33647-2435
Country : US
Telephone Number : 813-326-5417
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/08/2019
Last Update Date : 08/08/2019

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Directions to “ DEATRA MARTIN ” Practice Location

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