Basic Information
| Provider Information | |||||||||
| NPI: | 1740493956 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTELL | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | TERESE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LMSW, ACSW, SSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RACHOZA-MARTELL | ||||||||
| OtherFirstName: | GLORIA | ||||||||
| OtherMiddleName: | TERESE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW, LMSW, ACSW, SSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2525 CRESTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | ADRIAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492219262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343231355 | ||||||||
| FaxNumber: | 5172662763 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ADRIAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492212749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172655352 | ||||||||
| FaxNumber: | 5172636090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 1041C0700X | 6801063721 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.