Provider Demographics
NPI:1962485912
Name:MARTINEZ, TERRY MARTIN SR (LCSW)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:MARTIN
Last Name:MARTINEZ
Suffix:SR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 POPE AVE
Mailing Address - Street 2:MUNSON ARMY HEALTH CENTER ATTN MCXN COD MS COTTON
Mailing Address - City:FORT LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66027-2332
Mailing Address - Country:US
Mailing Address - Phone:913-684-6562
Mailing Address - Fax:913-684-6208
Practice Address - Street 1:4301 WILSON ST
Practice Address - Street 2:
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-4472
Practice Address - Country:US
Practice Address - Phone:580-442-3084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical