Provider Demographics
NPI:1518427137
Name:MARTINEZ, CANDACE DIANE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:DIANE
Last Name:MARTINEZ
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 1:13653 SANDPIPER PL
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-6875
Mailing Address - Country:US
Mailing Address - Phone:760-998-4098
Mailing Address - Fax:
Practice Address - Street 1:13653 SANDPIPER PL
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-6875
Practice Address - Country:US
Practice Address - Phone:760-998-4098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician