Healthcare Provider Details

I. General information

NPI: 1134479397
Provider Name (Legal Business Name): MISS MADELYNE MILDRED MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2632 E THOMAS RD STE 101
PHOENIX AZ
85016-8220
US

IV. Provider business mailing address

3200 MOTOR AVENUE
LOS ANGELES CA
90034
US

V. Phone/Fax

Practice location:
  • Phone: 602-957-2507
  • Fax: 602-957-2510
Mailing address:
  • Phone: 310-836-1223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW17998
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: