Healthcare Provider Details

I. General information

NPI: 1912182064
Provider Name (Legal Business Name): GEORGE MARIO MARTINEZ CERTIFED PSYCHOLOGIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BOGLE ST SUITE 102
SOMERSET KY
42503-3823
US

IV. Provider business mailing address

401 BOGLE ST SUITE 102
SOMERSET KY
42503-3823
US

V. Phone/Fax

Practice location:
  • Phone: 606-676-0638
  • Fax: 606-679-1889
Mailing address:
  • Phone: 606-676-0638
  • Fax: 606-679-1889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number0186
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: