Provider Demographics
NPI:1447877329
Name:NOLASCO, MARTIN FACUNDO (OTR/L)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:FACUNDO
Last Name:NOLASCO
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3670 N 54TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-2340
Mailing Address - Country:US
Mailing Address - Phone:786-262-4324
Mailing Address - Fax:
Practice Address - Street 1:3670 N 54TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-2340
Practice Address - Country:US
Practice Address - Phone:786-262-4324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT21051225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist