Provider Demographics
NPI:1134479397
Name:MARTINEZ, MADELYNE MILDRED
Entity Type:Individual
Prefix:MISS
First Name:MADELYNE
Middle Name:MILDRED
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 1:3200 MOTOR AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034
Mailing Address - Country:US
Mailing Address - Phone:310-836-1223
Mailing Address - Fax:
Practice Address - Street 1:2632 E THOMAS RD STE 101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-8220
Practice Address - Country:US
Practice Address - Phone:602-957-2507
Practice Address - Fax:602-957-2510
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW179981041C0700X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner