Healthcare Provider Details

I. General information

NPI: 1477082246
Provider Name (Legal Business Name): HAILEY NICOLE MARTINEZ PHD, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 06/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E 17TH ST
AMMON ID
83406-6601
US

IV. Provider business mailing address

1979 GRANDVIEW AVE
POCATELLO ID
83204-3655
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-7500
  • Fax:
Mailing address:
  • Phone: 208-241-0173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-6402
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: