Healthcare Provider Details

I. General information

NPI: 1457415325
Provider Name (Legal Business Name): RONALD MARTINEZ LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 OAKLAWN AVE
EAST MOLINE IL
61244-4030
US

IV. Provider business mailing address

550 OAKLAWN AVE
EAST MOLINE IL
61244
US

V. Phone/Fax

Practice location:
  • Phone: 309-792-1074
  • Fax:
Mailing address:
  • Phone: 309-792-1074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: