=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891703450
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN RICHARD MARTINDALE JR. M.ED., LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2006
-----------------------------------------------------
Last Update Date | 08/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1278 HILLCREST DR
-----------------------------------------------------
City | NEW BRAUNFELS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78130-3442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-624-0248
-----------------------------------------------------
Fax | 830-608-0215
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1331 ECHO MEADOW LN
-----------------------------------------------------
City | SPRING BRANCH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78070-5310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-885-5805
-----------------------------------------------------
Fax | 830-885-5805
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 18853
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------