Provider Demographics
NPI:1053673848
Name:MARTINEZ, THERESA (MS ED)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 42ND STREET
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-4917
Mailing Address - Country:US
Mailing Address - Phone:551-689-9638
Mailing Address - Fax:
Practice Address - Street 1:409 42ND STREET
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-4917
Practice Address - Country:US
Practice Address - Phone:551-689-9638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ540983174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist