Provider Demographics
NPI:1386879468
Name:MARTINEZ, HEIDI SHAUNA (MA, LPC)
Entity type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:SHAUNA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 S G ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1817
Mailing Address - Country:US
Mailing Address - Phone:541-947-6021
Mailing Address - Fax:541-219-8114
Practice Address - Street 1:35 S G ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1817
Practice Address - Country:US
Practice Address - Phone:541-947-6021
Practice Address - Fax:541-219-8114
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5279101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1386879468Medicaid