Basic Information
| Provider Information | |||||||||
| NPI: | 1295103158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | ANNIE | ||||||||
| MiddleName: | BILLIE JEAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JONES MARTINEZ | ||||||||
| OtherFirstName: | ANNIE | ||||||||
| OtherMiddleName: | BILLIE JEAN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15945 SE MILL ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972333663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035727089 | ||||||||
| FaxNumber: | 5032396233 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 SE 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032350131 | ||||||||
| FaxNumber: | 5032397390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2015 | ||||||||
| LastUpdateDate: | 06/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CADCI18-P-10 | OR | Y | Behavioral Health & Social Service Providers | Counselor | 175T00000X | N |
No ID Information.