Provider Demographics
NPI:1477082246
Name:MARTINEZ, HAILEY NICOLE (PHD, LCPC)
Entity Type:Individual
Prefix:MRS
First Name:HAILEY
Middle Name:NICOLE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PHD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1979 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-3655
Mailing Address - Country:US
Mailing Address - Phone:208-241-0173
Mailing Address - Fax:
Practice Address - Street 1:2705 E 17TH ST
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6601
Practice Address - Country:US
Practice Address - Phone:208-346-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-6402101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health