Provider Demographics
NPI:1578005815
Name:ALFONSO MARTINEZ, TAIMARA
Entity type:Individual
Prefix:
First Name:TAIMARA
Middle Name:
Last Name:ALFONSO MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6831 SW 147TH AVE APT 1B
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-1003
Mailing Address - Country:US
Mailing Address - Phone:786-856-4499
Mailing Address - Fax:
Practice Address - Street 1:10700 SW 46TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-4839
Practice Address - Country:US
Practice Address - Phone:786-907-4925
Practice Address - Fax:786-907-4972
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH20986101YM0800X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019313200Medicaid