Provider Demographics
NPI:1770747248
Name:MARTINEZ, CARMEN IVONNE (MA)
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:IVONNE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:VEGA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00692-0700
Mailing Address - Country:US
Mailing Address - Phone:787-810-8511
Mailing Address - Fax:
Practice Address - Street 1:CALLE LOLIN MIRANDA BLOQ 7 NUM 12
Practice Address - Street 2:SUITE 101
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-810-8511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2489103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool