Provider Demographics
NPI:1356484224
Name:MARTIN, BERTHA R (AS)
Entity Type:Individual
Prefix:MRS
First Name:BERTHA
Middle Name:R
Last Name:MARTIN
Suffix:
Gender:F
Credentials:AS
Other - Prefix:MRS
Other - First Name:BERTHA
Other - Middle Name:R
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AS
Mailing Address - Street 1:853 ENSENADA DR
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-1540
Mailing Address - Country:US
Mailing Address - Phone:951-251-2609
Mailing Address - Fax:
Practice Address - Street 1:853 ENSENADA DR
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-1540
Practice Address - Country:US
Practice Address - Phone:951-251-2609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor