Healthcare Provider Details

I. General information

NPI: 1508484460
Provider Name (Legal Business Name): DANIEL JAMES MARTINEZ LCDC INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2020
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 CRESTWAY RD STE 200B
WINDCREST TX
78239-1975
US

IV. Provider business mailing address

8611 DATAPOINT DR APT 49
SAN ANTONIO TX
78229-3249
US

V. Phone/Fax

Practice location:
  • Phone: 210-310-3864
  • Fax: 210-310-3719
Mailing address:
  • Phone: 512-962-7577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number47170
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: