Provider Demographics
NPI:1629663612
Name:MARTINEZ, BLANCA ESTELA
Entity Type:Individual
Prefix:
First Name:BLANCA
Middle Name:ESTELA
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 1:13 STEPHEN ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-2417
Mailing Address - Country:US
Mailing Address - Phone:617-852-0387
Mailing Address - Fax:
Practice Address - Street 1:176 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904-3230
Practice Address - Country:US
Practice Address - Phone:781-593-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222Q00000X
MA1922174226222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist