Provider Demographics
NPI:1477839843
Name:MARTIN, DOLORES K (MFT)
Entity Type:Individual
Prefix:
First Name:DOLORES
Middle Name:K
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1249 S DIAMOND BAR BLVD
Mailing Address - Street 2:SUITE 438
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4122
Mailing Address - Country:US
Mailing Address - Phone:909-482-1279
Mailing Address - Fax:
Practice Address - Street 1:1249 S DIAMOND BAR BLVD
Practice Address - Street 2:SUITE 438
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-4122
Practice Address - Country:US
Practice Address - Phone:909-482-1279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50659106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist