Provider Demographics
NPI:1275982977
Name:DIAZ, MARTHA VALLEJO (LPT)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:VALLEJO
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LPT
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Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:11277 GARDEN GROVE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1300
Mailing Address - Country:US
Mailing Address - Phone:714-620-8131
Mailing Address - Fax:
Practice Address - Street 1:11277 GARDEN GROVE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1300
Practice Address - Country:US
Practice Address - Phone:714-620-8131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29462167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician