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? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty |