Provider Demographics
NPI:1699177980
Name:MARTINEZ, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 FERN ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-1204
Mailing Address - Country:US
Mailing Address - Phone:978-476-0032
Mailing Address - Fax:
Practice Address - Street 1:41 FERN ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-1204
Practice Address - Country:US
Practice Address - Phone:978-476-0032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker