=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528499613
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IDANIA E MARTINEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2013
-----------------------------------------------------
Last Update Date | 08/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1250 S KING RD
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95122-2146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 669-306-1874
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 251 LLEWELLYN AVE
-----------------------------------------------------
City | CAMPBELL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95008-1940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------