Provider Demographics
NPI:1073647111
Name:MARTIN, TINA R
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:R
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-3113
Mailing Address - Country:US
Mailing Address - Phone:925-685-7613
Mailing Address - Fax:925-685-4325
Practice Address - Street 1:1121 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-3113
Practice Address - Country:US
Practice Address - Phone:925-685-7613
Practice Address - Fax:925-685-4325
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)