MEDICARE: GUSTAVO MARTINEZ

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0056RY	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1336392968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUSTAVO MARTINEZ

Provider Business Mailing Address
First Line	:	814 MYRTLE AVE
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79901-1512
Country	:	US
Telephone Number	:	915-241-7272
Fax Number	:	877-587-9452

Provider Business Practice Location Address
First Line	:	814 MYRTLE AVE
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79901-1512
Country	:	US
Telephone Number	:	915-241-7272
Fax Number	:	877-587-9452

Authorized Official
Title or Position	:	OWNER
Name	:	GUSTAVO R MARTINEZ
Credential	:	LCSW
Telephone Number	:	915-241-7272

Provider Enumeration Date	:	10/28/2008
Last Update Date	:	07/10/2009

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Directions to “GUSTAVO MARTINEZ ” Practice Location

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