Provider Demographics
NPI:1720763261
Name:MARTINEZ, ENRIQUE N/A
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:N/A
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 1:8628 PAPER BIRCH LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-5058
Mailing Address - Country:US
Mailing Address - Phone:682-551-7175
Mailing Address - Fax:
Practice Address - Street 1:8628 PAPER BIRCH LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-5058
Practice Address - Country:US
Practice Address - Phone:682-551-7175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX90463101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor