Provider Demographics
NPI:1619640265
Name:MARTINEZ, STACEY ANN (LPC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 S HELEN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3513
Mailing Address - Country:US
Mailing Address - Phone:208-550-2879
Mailing Address - Fax:
Practice Address - Street 1:690 S INDUSTRY WAY STE 45
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7907
Practice Address - Country:US
Practice Address - Phone:208-922-2207
Practice Address - Fax:208-922-4168
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-8206101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor