Provider Demographics
NPI:1528180049
Name:MARTINEZ, FIDEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:FIDEL
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 DOREMUS RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2768
Mailing Address - Country:US
Mailing Address - Phone:323-646-1555
Mailing Address - Fax:
Practice Address - Street 1:1285 DOREMUS RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2768
Practice Address - Country:US
Practice Address - Phone:323-646-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS95051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMS171130OtherMEDICAL PROVIDER NUMBER
CA012130Medicaid