Provider Demographics
NPI:1851012397
Name:MARTINEZ, ANGELIQUE TERRY
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:TERRY
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 1:708 S LINDON LN # 4013-C
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-3221
Mailing Address - Country:US
Mailing Address - Phone:720-940-8375
Mailing Address - Fax:
Practice Address - Street 1:4350 E RAY ROAD
Practice Address - Street 2:BUILDING 2- SUITE 109
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281
Practice Address - Country:US
Practice Address - Phone:602-666-5101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician