Provider Demographics
NPI:1558704676
Name:MARTIN, WILBERT JR (LPT)
Entity Type:Individual
Prefix:MR
First Name:WILBERT
Middle Name:
Last Name:MARTIN
Suffix:JR
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 UTIL CIR
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-6188
Mailing Address - Country:US
Mailing Address - Phone:805-253-4014
Mailing Address - Fax:
Practice Address - Street 1:5740 RALSTON ST STE 200
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6009
Practice Address - Country:US
Practice Address - Phone:805-289-3124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22411101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health