Provider Demographics
NPI:1205489614
Name:MARTINEZ, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-3413
Mailing Address - Country:US
Mailing Address - Phone:718-728-8476
Mailing Address - Fax:718-204-7570
Practice Address - Street 1:2509 BROADWAY
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-3413
Practice Address - Country:US
Practice Address - Phone:718-728-8476
Practice Address - Fax:718-204-7570
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0998981104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0998981Medicaid