Healthcare Provider Details

I. General information

NPI: 1578043402
Provider Name (Legal Business Name): ERICA MARTINEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 MARINA DR
LAKE WORTH TX
76135-2835
US

IV. Provider business mailing address

8210 VILLA LAGO DR APT 227
FORT WORTH TX
76179-2237
US

V. Phone/Fax

Practice location:
  • Phone: 817-237-7231
  • Fax:
Mailing address:
  • Phone: 940-453-9068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number102498
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: