Healthcare Provider Details

I. General information

NPI: 1255305504
Provider Name (Legal Business Name): SAMANTHA S MARTINEZ LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 HOLMES STREET
QUINCY MA
02171
US

IV. Provider business mailing address

97 HOLMES ST
QUINCY MA
02171-2433
US

V. Phone/Fax

Practice location:
  • Phone: 781-866-9497
  • Fax: 617-770-1174
Mailing address:
  • Phone: 617-298-0592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number112033
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number112033
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number112033
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: