Provider Demographics
NPI:1396402798
Name:MARTIN, MIKI
Entity Type:Individual
Prefix:
First Name:MIKI
Middle Name:
Last Name:MARTIN
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 1:24421 VIA PALOMINO CT APT 4
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-3507
Mailing Address - Country:US
Mailing Address - Phone:562-326-8391
Mailing Address - Fax:
Practice Address - Street 1:600 CORPORATE DR STE 110
Practice Address - Street 2:
Practice Address - City:LADERA RANCH
Practice Address - State:CA
Practice Address - Zip Code:92694-2107
Practice Address - Country:US
Practice Address - Phone:949-661-6753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst