Provider Demographics
NPI:1952789778
Name:INTEGRATED COUNSELING & MEDIATION SERVICES
Entity Type:Organization
Organization Name:INTEGRATED COUNSELING & MEDIATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIRTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ-KEKENAK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:347-852-0020
Mailing Address - Street 1:801 INTERNATIONAL PKWY FL 5
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4762
Mailing Address - Country:US
Mailing Address - Phone:347-852-0020
Mailing Address - Fax:
Practice Address - Street 1:801 INTERNATIONAL PKWY FL 5
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4762
Practice Address - Country:US
Practice Address - Phone:347-852-0020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty