Provider Demographics
NPI:1205370301
Name:MARTINEZ, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
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 1:19 STICKNEY HILL RD
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:CT
Mailing Address - Zip Code:06076-4621
Mailing Address - Country:US
Mailing Address - Phone:860-729-7133
Mailing Address - Fax:
Practice Address - Street 1:548 PARK AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-2537
Practice Address - Country:US
Practice Address - Phone:774-823-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program