Provider Demographics
NPI:1114403136
Name:MARTINEZ, LAURA MARIA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIA
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 1:455 FOX HILLS DR N
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-1309
Mailing Address - Country:US
Mailing Address - Phone:248-253-7372
Mailing Address - Fax:
Practice Address - Street 1:1777 AXTELL DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4404
Practice Address - Country:US
Practice Address - Phone:247-709-5981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010837981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical