Provider Demographics
NPI:1912182064
Name:MARTINEZ, GEORGE MARIO (CERTIFED PSYCHOLOGIC)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:MARIO
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:CERTIFED PSYCHOLOGIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 BOGLE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3823
Mailing Address - Country:US
Mailing Address - Phone:606-676-0638
Mailing Address - Fax:606-679-1889
Practice Address - Street 1:401 BOGLE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3823
Practice Address - Country:US
Practice Address - Phone:606-676-0638
Practice Address - Fax:606-679-1889
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0186103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral