Provider Demographics
NPI:1700323359
Name:MARTINEZ GONZALEZ, SELYSMARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:SELYSMARIE
Middle Name:
Last Name:MARTINEZ GONZALEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207B CIRCULO C
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00603-1246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BUEN SAMARITANO MEDICAL & PROFESSIONAL PLAZA
Practice Address - Street 2:SUITE #5 PRIMER PISO AVE. SEVERIANO CUEVAS #18
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:787-560-6237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
PR6383103TA0700X, 103TC2200X, 103TH0004X, 103TH0100X, 103TP2701X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1134107113OtherFALLON
MA997303OtherNETWORK HEALTH
MA1134107113Medicaid
MA042622756OtherCCA
MA71756OtherTUFTS
MA1134107113OtherMBHP
MA1134107113OtherBEACON
MA1134107113OtherNHP
MA12529OtherHNE
MA71756OtherTUFTS