Healthcare Provider Details

I. General information

NPI: 1477489771
Provider Name (Legal Business Name): JOE MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 DEARBORN ST
CALDWELL ID
83605-4116
US

IV. Provider business mailing address

709 DEARBORN ST
CALDWELL ID
83605-4116
US

V. Phone/Fax

Practice location:
  • Phone: 208-376-7083
  • Fax: 208-402-5604
Mailing address:
  • Phone: 208-376-7083
  • Fax: 208-402-5604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDA-13071
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: