Basic Information
| Provider Information | |||||||||
| NPI: | 1093277253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | RACHEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRIEDLAENDER | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | RACHEL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | TLLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30150 TELEGRAPH RD STE 245 | ||||||||
| Address2: | |||||||||
| City: | BINGHAM FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480254521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
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| Practice Location | |||||||||
| Address1: | 30150 TELEGRAPH RD STE 245 | ||||||||
| Address2: | |||||||||
| City: | BINGHAM FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480254521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006931916 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2019 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301018348 | MI | N | Behavioral Health & Social Service Providers | Psychologist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 103T00000X | 6361007646 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.