Provider Demographics
NPI:1679823009
Name:MARTINEZ, LUIS (MS ED)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 E 172ND ST
Mailing Address - Street 2:APARTMENT 1-R
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-2154
Mailing Address - Country:US
Mailing Address - Phone:917-538-6519
Mailing Address - Fax:
Practice Address - Street 1:1511 E 172ND ST
Practice Address - Street 2:APARTMENT 1-R
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-2154
Practice Address - Country:US
Practice Address - Phone:917-538-6519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221796031103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool