MEDICARE: MR. MARTIN AVELLANEDA JR.

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1912651001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARTIN AVELLANEDA JR.

Provider Business Mailing Address
First Line	:	1602 FORT MEADE RD
Second Line	:
City	:	FROSTPROOF
State	:	FL
Zip	:	33843-9531
Country	:	US
Telephone Number	:	863-605-4616
Fax Number	:

Provider Business Practice Location Address
First Line	:	244 E PARK AVE
Second Line	:
City	:	LAKE WALES
State	:	FL
Zip	:	33853-3706
Country	:	US
Telephone Number	:	863-605-4616
Fax Number	:

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

Provider Enumeration Date	:	02/08/2022
Last Update Date	:	02/08/2022

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