Provider Demographics
NPI:1497408827
Name:MARTIN, LAURYN SYMONE
Entity Type:Individual
Prefix:
First Name:LAURYN
Middle Name:SYMONE
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 1:11249 TERRA VISTA PKWY APT F
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7411
Mailing Address - Country:US
Mailing Address - Phone:909-518-7169
Mailing Address - Fax:
Practice Address - Street 1:801 CORPORATE CENTER DR STE 210
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-2627
Practice Address - Country:US
Practice Address - Phone:909-618-0974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician