Provider Demographics
NPI:1194235952
Name:MARTINEZ, EPIFANIO RAY (BS,FS, LCDC III)
Entity type:Individual
Prefix:
First Name:EPIFANIO
Middle Name:RAY
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:BS,FS, LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3964 HAMILTON SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-9119
Mailing Address - Country:US
Mailing Address - Phone:614-916-6571
Mailing Address - Fax:
Practice Address - Street 1:3964 HAMILTON SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-9119
Practice Address - Country:US
Practice Address - Phone:614-916-6571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH131073101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)