Provider Demographics
NPI:1902307630
Name:MARTINEZ, VIRGINIA (MA, TLLP)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 S TELEGRAPH RD STE 102
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0177
Mailing Address - Country:US
Mailing Address - Phone:248-341-3399
Mailing Address - Fax:
Practice Address - Street 1:1750 S TELEGRAPH RD STE 102
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302
Practice Address - Country:US
Practice Address - Phone:248-341-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017341103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling