Provider Demographics
NPI:1326185323
Name:MARTINEZ, JUAN CRISTOBAL (LCSW)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CRISTOBAL
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6438 PITT CT
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95842-2636
Mailing Address - Country:US
Mailing Address - Phone:916-348-7474
Mailing Address - Fax:
Practice Address - Street 1:3175 SUNSET BLVD
Practice Address - Street 2:SUITE 104A
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-3091
Practice Address - Country:US
Practice Address - Phone:916-952-3837
Practice Address - Fax:916-348-1520
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 55391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9413OtherPROVIDER ID