MEDICARE: DAFNE 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	103T00000X	Psychologist	11697733	NM
2	103T00000X	Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780309369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAFNE MARTINEZ

Provider Business Mailing Address
First Line	:	2433 N WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2028
Country	:	US
Telephone Number	:	773-827-6109
Fax Number	:

Provider Business Practice Location Address
First Line	:	3228 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-4919
Country	:	US
Telephone Number	:	773-827-6109
Fax Number	:

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

Provider Enumeration Date	:	10/06/2022
Last Update Date	:	01/12/2024

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Directions to “ DAFNE MARTINEZ ” Practice Location

Language	Start Address	Practice Location

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