Provider Demographics
NPI:1548743206
Name:MARTIN, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
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 1:8788 ELK GROVE BLVD STE L
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-1768
Mailing Address - Country:US
Mailing Address - Phone:916-775-3626
Mailing Address - Fax:
Practice Address - Street 1:8788 ELK GROVE BLVD STE L
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1768
Practice Address - Country:US
Practice Address - Phone:916-775-3626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health