Provider Demographics
NPI:1417546201
Name:MARTINEZ, ALYSSA M (MSED)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:M
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 PETER PAUL DR
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-3535
Mailing Address - Country:US
Mailing Address - Phone:631-383-2460
Mailing Address - Fax:
Practice Address - Street 1:743 PETER PAUL DR
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-3535
Practice Address - Country:US
Practice Address - Phone:631-383-2460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1185807171252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency