Provider Demographics
NPI:1114764990
Name:MARTINEZ, GLORIA BRIGUITE
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:BRIGUITE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S78W29444 FROG ALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-9704
Mailing Address - Country:US
Mailing Address - Phone:262-389-7565
Mailing Address - Fax:
Practice Address - Street 1:4570 S 27TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-2145
Practice Address - Country:US
Practice Address - Phone:414-290-4105
Practice Address - Fax:414-290-4574
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist