Healthcare Provider Details

I. General information

NPI: 1730726753
Provider Name (Legal Business Name): BRIAN SHAWN MARTINEZDELACOTERA LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11649 N PORT WASHINGTON RD STE 221
MEQUON WI
53092-3461
US

IV. Provider business mailing address

4800 N SCOTTSDALE RD STE 2500
SCOTTSDALE AZ
85251-7630
US

V. Phone/Fax

Practice location:
  • Phone: 262-912-1922
  • Fax:
Mailing address:
  • Phone: 262-999-3495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6996-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: