Provider Demographics
NPI:1891161964
Name:MARTINEZ, BLAKE (MA)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-1907
Mailing Address - Country:US
Mailing Address - Phone:231-726-2299
Mailing Address - Fax:
Practice Address - Street 1:1148 4TH ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-1907
Practice Address - Country:US
Practice Address - Phone:231-726-2299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016267103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical