Basic Information
| Provider Information | |||||||||
| NPI: | 1114475415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | CLARISSA | ||||||||
| MiddleName: | MILDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37 BRUNO ST | ||||||||
| Address2: | |||||||||
| City: | MOONACHIE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070741131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014142913 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6 FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | PARAMUS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076525241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5512459090 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 11/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.