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General NPI Number Information
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NPI Number | 1235314618
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Entity Type | Individual
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Provider Name | AMBROSIO MARTINEZ LCSW
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Gender | Male
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Dates
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Enumeration Date | 01/04/2008
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Last Update Date | 01/04/2008
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Provider Practice Location Address
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Address Line | 3720 W 26TH ST
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City | CHICAGO
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State | IL
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Zip | 60623-3824
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Country | US
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Telephone | 773-277-2225
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Fax |
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Provider Business Mailing Address
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Address Line | 2725 W 22ND PL
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City | CHICAGO
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State | IL
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Zip | 60608-3507
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Country | US
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Telephone | 773-577-6182
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149.007704
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License Number State | IL
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