Healthcare Provider Details

I. General information

NPI: 1194013391
Provider Name (Legal Business Name): MARTIN CUELLAR LCDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2011
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 W NOLANA LOOP
PHARR TX
78577-8340
US

IV. Provider business mailing address

151 E LOS TORRITOS ST
WESLACO TX
78596-5333
US

V. Phone/Fax

Practice location:
  • Phone: 956-502-5526
  • Fax:
Mailing address:
  • Phone: 956-463-7117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number9849
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: