Provider Demographics
NPI:1629085857
Name:MARTINEZ, FIDEL RICARDO (LCSW, CEAP)
Entity Type:Individual
Prefix:MR
First Name:FIDEL
Middle Name:RICARDO
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:LCSW, CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:720 45TH ST
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2818
Practice Address - Country:US
Practice Address - Phone:219-852-2513
Practice Address - Fax:219-852-2443
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490011271041C0700X
IN87000616A1041C0700X
IN34004064A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL90000854OtherBCBSIL
IN408460RMedicare PIN