Provider Demographics
NPI:1255305504
Name:MARTINEZ, SAMANTHA S (LICSW)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:S
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 HOLMES ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171-2433
Mailing Address - Country:US
Mailing Address - Phone:617-298-0592
Mailing Address - Fax:
Practice Address - Street 1:97 HOLMES STREET
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02171
Practice Address - Country:US
Practice Address - Phone:781-866-9497
Practice Address - Fax:617-770-1174
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA112033101YP2500X, 1041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMAP23849Medicare ID - Type Unspecified