Provider Demographics
NPI:1851962021
Name:ZALDIVAR, MARTIN ANTONIO (LMSW)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:ANTONIO
Last Name:ZALDIVAR
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 E CONCORD ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-9259
Mailing Address - Country:US
Mailing Address - Phone:415-216-3095
Mailing Address - Fax:
Practice Address - Street 1:650 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-4429
Practice Address - Country:US
Practice Address - Phone:918-587-9471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7836104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker