MEDICARE: TRACIE JUANETTE MARTIN

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	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5630	OTHER	TX	COMMUNITY HEALTH WORKER

General Provider Information

NPI Number	:	1881174506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACIE JUANETTE MARTIN

Provider Business Mailing Address
First Line	:	8440 N SAM HOUSTON PKWY E APT 1326
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77396-2980
Country	:	US
Telephone Number	:	409-543-3300
Fax Number	:

Provider Business Practice Location Address
First Line	:	8440 N SAM HOUSTON PKWY E APT 1326
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77396-2980
Country	:	US
Telephone Number	:	409-543-3300
Fax Number	:

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

Provider Enumeration Date	:	08/21/2018
Last Update Date	:	08/21/2018

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Directions to “ TRACIE JUANETTE MARTIN ” Practice Location

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