Provider Demographics
NPI:1134308950
Name:REA, MARTHA ANGELICA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:ANGELICA
Last Name:REA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2268 GARNET DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-8376
Mailing Address - Country:US
Mailing Address - Phone:510-428-3885
Mailing Address - Fax:510-610-3912
Practice Address - Street 1:747 52ND ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1809
Practice Address - Country:US
Practice Address - Phone:510-428-3885
Practice Address - Fax:510-601-3912
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 208251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS 20825OtherCLINICAL SOCIAL WORKER