Provider Demographics
NPI:1669232245
Name:MARTINEZ, VANESSA MARIE (TCADC)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:MARIE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:TCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 PIKES PEAK BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-1160
Mailing Address - Country:US
Mailing Address - Phone:270-243-7609
Mailing Address - Fax:
Practice Address - Street 1:1700 CARGO CT
Practice Address - Street 2:
Practice Address - City:JEFFERSONTOWN
Practice Address - State:KY
Practice Address - Zip Code:40299-1938
Practice Address - Country:US
Practice Address - Phone:800-805-6989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY282011101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)