Provider Demographics
NPI:1518511930
Name:DEZA, MARTIN J (LMFT)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:J
Last Name:DEZA
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13060 VIA CABALLO ROJO
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-3042
Mailing Address - Country:US
Mailing Address - Phone:760-445-5609
Mailing Address - Fax:
Practice Address - Street 1:13060 VIA CABALLO ROJO
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-3042
Practice Address - Country:US
Practice Address - Phone:760-445-5609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106348101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health