Provider Demographics
NPI:1013506054
Name:MARTINEZ, MICAELA LUISA (PTA)
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:LUISA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 ASPEN DR APT D
Mailing Address - Street 2:
Mailing Address - City:ANDREWS
Mailing Address - State:TX
Mailing Address - Zip Code:79714-3841
Mailing Address - Country:US
Mailing Address - Phone:309-756-7331
Mailing Address - Fax:
Practice Address - Street 1:711 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:DENVER CITY
Practice Address - State:TX
Practice Address - Zip Code:79323-3000
Practice Address - Country:US
Practice Address - Phone:817-542-5493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2159576225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant