Provider Demographics
NPI:1629521471
Name:SMITH, MARTINA MAAIKE
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:MAAIKE
Last Name:SMITH
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 1:574 COUNTY ROAD 4641
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:TX
Mailing Address - Zip Code:75490-6420
Mailing Address - Country:US
Mailing Address - Phone:252-722-2988
Mailing Address - Fax:
Practice Address - Street 1:574 COUNTY ROAD 4641
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:TX
Practice Address - Zip Code:75490-6420
Practice Address - Country:US
Practice Address - Phone:252-722-2988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX889966171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ00144025OtherBOARD CERTIFIED CASE MANAGER