Provider Demographics
NPI:1144601766
Name:MARTIN, SHANICE
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:
Last Name:MARTIN
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 1:1575 DELUCCHI LN
Mailing Address - Street 2:STE. #220
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-6578
Mailing Address - Country:US
Mailing Address - Phone:775-825-7500
Mailing Address - Fax:
Practice Address - Street 1:1575 DELUCCHI LN
Practice Address - Street 2:STE. #220
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-6578
Practice Address - Country:US
Practice Address - Phone:775-825-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV82Medicaid