Provider Demographics
NPI:1164555330
Name:MARTINEZ DIAZ, GINA MARIE
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:MARTINEZ DIAZ
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 1:11716 ENTERPRISE DRIVE - CSOC
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603
Mailing Address - Country:US
Mailing Address - Phone:530-889-6769
Mailing Address - Fax:
Practice Address - Street 1:9201 BIG HORN BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-1240
Practice Address - Country:US
Practice Address - Phone:916-478-5016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT105043106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist