Basic Information
| Provider Information | |||||||||
| NPI: | 1629663612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | BLANCA | ||||||||
| MiddleName: | ESTELA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 13 STEPHEN ST | ||||||||
| Address2: | |||||||||
| City: | LYNN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019022417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178520387 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 176 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | LYNN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019043230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815932727 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2021 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | 222Q00000X | 1922174226 | MA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.