=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528284858
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDGARD REINALDO MARTINEZ SR. M.S. PH. D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | GENERAL VALERO AVENUE SUITE 313A SECOND LEVEL
-----------------------------------------------------
City | FAJARDO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00738-1464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-632-5909
-----------------------------------------------------
Fax | 787-860-1463
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1464 P.O. BOX 1464
-----------------------------------------------------
City | FAJARDO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00738-1464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-632-5909
-----------------------------------------------------
Fax | 787-860-1463
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 689
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------