MEDICARE: DEIRDRE MARY MARTINEZ BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-16-23249	WA

General Provider Information

NPI Number	:	1720500234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIRDRE MARY MARTINEZ BCBA

Provider Business Mailing Address
First Line	:	7313 S JACKSON ST
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80122-2215
Country	:	US
Telephone Number	:	720-217-5136
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 S WADSWORTH BLVD STE 303
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80227-3246
Country	:	US
Telephone Number	:	720-962-4555
Fax Number	:	720-962-4466

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2017
Last Update Date	:	07/17/2017

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