Healthcare Provider Details

I. General information

NPI: 1063369817
Provider Name (Legal Business Name): PRICILLA MYRLEEN MARTINEZ MHC-LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2026
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 GRAND CONCOURSE APT 5K
BRONX NY
10458-1225
US

IV. Provider business mailing address

3130 GRAND CONCOURSE APT 5K
BRONX NY
10458-1225
US

V. Phone/Fax

Practice location:
  • Phone: 917-975-0578
  • Fax:
Mailing address:
  • Phone: 917-975-0578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP132147
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: