Provider Demographics
NPI:1497262919
Name:MARTIN, CLARISSA KATHERINE
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:KATHERINE
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 1:16250 HOMECOMING DR UNIT 1149
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91708-8805
Mailing Address - Country:US
Mailing Address - Phone:951-404-6083
Mailing Address - Fax:
Practice Address - Street 1:16250 HOMECOMING DR UNIT 1149
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91708-8805
Practice Address - Country:US
Practice Address - Phone:951-404-6083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00001847106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician