Provider Demographics
NPI:1073640801
Name:MARTINEZ-DIAZ, WANDA MARGARITA (MHC)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:MARGARITA
Last Name:MARTINEZ-DIAZ
Suffix:
Gender:F
Credentials:MHC
Other - Prefix:DR
Other - First Name:WANDA
Other - Middle Name:MARGARITA
Other - Last Name:MARTINEZ-DIAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MHC
Mailing Address - Street 1:42 DEERFIELD ST # 1
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-4363
Mailing Address - Country:US
Mailing Address - Phone:508-421-4478
Mailing Address - Fax:508-795-1338
Practice Address - Street 1:85 GREEN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-4134
Practice Address - Country:US
Practice Address - Phone:508-755-3737
Practice Address - Fax:508-795-1665
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8462101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional