Provider Demographics
NPI:1114676236
Name:MARTIN, PATRICIA DIANE
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:DIANE
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 1:4000 N CENTRAL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3520
Mailing Address - Country:US
Mailing Address - Phone:602-285-9779
Mailing Address - Fax:
Practice Address - Street 1:77 N CAMINO SECO APT 152
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-2969
Practice Address - Country:US
Practice Address - Phone:520-809-1596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10480995385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child