Provider Demographics
NPI:1245577717
Name:MARTINEZ, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
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 1:2800 E WHITESTONE BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-7275
Mailing Address - Country:US
Mailing Address - Phone:512-986-7625
Mailing Address - Fax:
Practice Address - Street 1:2205 S BAGDAD RD
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-2311
Practice Address - Country:US
Practice Address - Phone:512-986-7625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
TX3906106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator