Provider Demographics
NPI:1619640265
Name:MARTINEZ, STACEY ANN (LCPC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6421
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-6421
Mailing Address - Country:US
Mailing Address - Phone:986-279-3252
Mailing Address - Fax:
Practice Address - Street 1:3350 W AMERICANA TER STE 210A
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2521
Practice Address - Country:US
Practice Address - Phone:986-279-3252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-8206101Y00000X
ID8331174101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor