Provider Demographics
NPI:1447744875
Name:MARTINEZ, MALLORY K (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:K
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13509 83RD AVE APT 3F
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-1577
Mailing Address - Country:US
Mailing Address - Phone:646-573-6742
Mailing Address - Fax:
Practice Address - Street 1:13509 83RD AVE APT 3F
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-1577
Practice Address - Country:US
Practice Address - Phone:646-573-6742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0857471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical