Provider Demographics
NPI:1407981624
Name:MARTINEZ, BRIAN (AMFT 107412)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:AMFT 107412
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 ROYALTY DR STE 180
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3046
Mailing Address - Country:US
Mailing Address - Phone:909-766-7317
Mailing Address - Fax:
Practice Address - Street 1:1900 ROYALTY DR
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3032
Practice Address - Country:US
Practice Address - Phone:909-766-7317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA107412106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist