Provider Demographics
NPI:1649288390
Name:MARTINEZ, ROLANDO THOMAS (MSW, LCSW, LADC)
Entity type:Individual
Prefix:MR
First Name:ROLANDO
Middle Name:THOMAS
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:MSW, LCSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4700
Mailing Address - Country:US
Mailing Address - Phone:860-444-5141
Mailing Address - Fax:860-442-4079
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-444-5141
Practice Address - Fax:860-442-4079
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000839101YA0400X
CT0010951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400060106OtherMEDICARE
CT1649288390Medicaid