Provider Demographics
NPI:1336600907
Name:MARTIN, MELISSA (MS)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 2 BOX 6945
Mailing Address - Street 2:
Mailing Address - City:HORMIGUEROS
Mailing Address - State:PR
Mailing Address - Zip Code:00660
Mailing Address - Country:US
Mailing Address - Phone:787-640-9445
Mailing Address - Fax:
Practice Address - Street 1:60 CALLE MEDITACION
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-4819
Practice Address - Country:US
Practice Address - Phone:787-832-7134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6232103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty