Provider Demographics
NPI:1508423138
Name:MARTINEZ, ICELLE GRACE VILLANUEVA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ICELLE GRACE
Middle Name:VILLANUEVA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36313 ST ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-4130
Mailing Address - Country:US
Mailing Address - Phone:248-805-2622
Mailing Address - Fax:
Practice Address - Street 1:36313 ST ANDREWS DR
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-4130
Practice Address - Country:US
Practice Address - Phone:248-805-2622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012216208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty