Healthcare Provider Details

I. General information

NPI: 1447872783
Provider Name (Legal Business Name): SEFERINO MARTINEZ JR. LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2020
Last Update Date: 05/09/2020
Certification Date: 05/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 S VAN DORN ST
KINGSTOWNE VA
22315
US

IV. Provider business mailing address

109 PELICAN CV
STAFFORD VA
22554-4513
US

V. Phone/Fax

Practice location:
  • Phone: 703-313-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701009059
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: