Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) |
NPI | 1265072763 |
---|---|
Provider Name | Misael Martinez |
First Address | Middletown, NY 10940-4511 |
Second Address | Port Chester, NY 10573-7614 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/01/2020 |
Last Update Date | 13/01/2020 |