Provider Demographics
NPI:1457775678
Name:MARTINEZ, ANTONIO
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:500 SYCAMORE LN
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:TX
Mailing Address - Zip Code:79045-2817
Mailing Address - Country:US
Mailing Address - Phone:806-223-3174
Mailing Address - Fax:
Practice Address - Street 1:500 SYCAMORE LN
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:TX
Practice Address - Zip Code:79045-2817
Practice Address - Country:US
Practice Address - Phone:806-223-3174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55002101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional