Provider Demographics
NPI:1871157230
Name:MARTINEZ, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 CALLE SAN JOAQUIN
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-5337
Mailing Address - Country:US
Mailing Address - Phone:787-632-7688
Mailing Address - Fax:
Practice Address - Street 1:1880 CALLE SAN JOAQUIN
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-5337
Practice Address - Country:US
Practice Address - Phone:787-632-7688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1423103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical