MEDICARE: TERESA ALEGRIA MARTINEZ LCSW

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	1041C0700X	Clinical Social Worker	10745	LA

General Provider Information

NPI Number	:	1215222914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA ALEGRIA MARTINEZ LCSW

Provider Business Mailing Address
First Line	:	2924 KNIGHT ST
Second Line	:	STE. 434
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-2415
Country	:	US
Telephone Number	:	318-631-1122
Fax Number	:	318-866-9622

Provider Business Practice Location Address
First Line	:	2924 KNIGHT ST
Second Line	:	STE. 434
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-2415
Country	:	US
Telephone Number	:	318-631-1122
Fax Number	:	318-866-9622

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

Provider Enumeration Date	:	06/10/2011
Last Update Date	:	06/10/2011

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