Provider Demographics
NPI:1073268959
Name:MARTINEZ, MEGAN ALEXA
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:ALEXA
Last Name: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 1:715 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-1529
Mailing Address - Country:US
Mailing Address - Phone:989-482-7518
Mailing Address - Fax:
Practice Address - Street 1:6296 BRIDGEPORT VILLAGE SQUARE DR
Practice Address - Street 2:SUITE #2
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602
Practice Address - Country:US
Practice Address - Phone:989-401-1239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician