MEDICARE: MR. MARTIN CUELLAR LCDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	9849	TX

General Provider Information

NPI Number	:	1194013391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARTIN CUELLAR LCDC

Provider Business Mailing Address
First Line	:	151 E LOS TORRITOS ST
Second Line	:
City	:	WESLACO
State	:	TX
Zip	:	78596-5333
Country	:	US
Telephone Number	:	956-463-7117
Fax Number	:

Provider Business Practice Location Address
First Line	:	918 W NOLANA LOOP
Second Line	:
City	:	PHARR
State	:	TX
Zip	:	78577-8340
Country	:	US
Telephone Number	:	956-502-5526
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2011
Last Update Date	:	07/21/2011

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