Healthcare Provider Details

I. General information

NPI: 1093295750
Provider Name (Legal Business Name): ELIZBETH MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 E NAVARRO AVE
DE LEON TX
76444-1275
US

IV. Provider business mailing address

1000 E LINGLEVILLE RD APT 517
STEPHENVILLE TX
76401-2128
US

V. Phone/Fax

Practice location:
  • Phone: 254-893-2075
  • Fax:
Mailing address:
  • Phone: 870-279-4330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number215067
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: