Provider Demographics
NPI:1770367906
Name:MARTINEZ, EDWARD CONRADO (LCSW)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:CONRADO
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINSTED
Mailing Address - State:CT
Mailing Address - Zip Code:06098-1740
Mailing Address - Country:US
Mailing Address - Phone:860-201-3414
Mailing Address - Fax:
Practice Address - Street 1:187 S CANAAN RD
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06018-2544
Practice Address - Country:US
Practice Address - Phone:877-200-0637
Practice Address - Fax:860-945-4282
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT03-045639101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health