Provider Demographics
NPI:1457677395
Name:MARTIN, SHELLEY (LMFT)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27120 EUCALYPTUS AVE STE G162
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4543
Mailing Address - Country:US
Mailing Address - Phone:661-303-6975
Mailing Address - Fax:951-242-8741
Practice Address - Street 1:9220 HAVEN AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-8551
Practice Address - Country:US
Practice Address - Phone:951-394-1903
Practice Address - Fax:951-242-8741
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105626106H00000X
CAIMF79572106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist