Provider Demographics
NPI:1629366174
Name:MARTINEZ, MAXINE K
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:K
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3507 LOOP 20
Mailing Address - Street 2:SUITE 7A
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78043-4743
Mailing Address - Country:US
Mailing Address - Phone:956-753-5600
Mailing Address - Fax:956-753-5602
Practice Address - Street 1:3507 LOOP 20
Practice Address - Street 2:SUITE 7A
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78043-4743
Practice Address - Country:US
Practice Address - Phone:956-753-5600
Practice Address - Fax:956-753-5602
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112475235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112475OtherSTATE LICENSE