Provider Demographics
NPI:1902332687
Name:MARTINEZ, DIEGO (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DIEGO
Middle Name:
Last Name:MARTINEZ
Suffix:
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 1:16318 JAMAICA AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-4901
Mailing Address - Country:US
Mailing Address - Phone:718-651-7770
Mailing Address - Fax:
Practice Address - Street 1:16318 JAMAICA AVE STE 2
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4901
Practice Address - Country:US
Practice Address - Phone:718-651-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102427104100000X
NY0910871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVE01546SMedicaid