Healthcare Provider Details

I. General information

NPI: 1679596225
Provider Name (Legal Business Name): MILDRED MARTINEZ MENTAL HEALTH COUNSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 LAFAYETTE AVE
BRONX NY
10474-5336
US

IV. Provider business mailing address

1241 LAFAYETTE AVE
BRONX NY
10474-5336
US

V. Phone/Fax

Practice location:
  • Phone: 718-378-6500
  • Fax: 718-842-3846
Mailing address:
  • Phone: 718-378-6500
  • Fax: 718-842-3846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number002638
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: