Provider Demographics
NPI:1710265962
Name:MARTINEZ, CARLOS (MSED)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 WALLACE AVE
Mailing Address - Street 2:APT 3C
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-1860
Mailing Address - Country:US
Mailing Address - Phone:718-822-0127
Mailing Address - Fax:
Practice Address - Street 1:369 E 148TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4041
Practice Address - Country:US
Practice Address - Phone:718-769-2698
Practice Address - Fax:718-764-6469
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY754704103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst