Provider Demographics
NPI:1598383044
Name:MARTINEZ, KELLEY
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
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 1:1940 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2148
Mailing Address - Country:US
Mailing Address - Phone:909-392-1344
Mailing Address - Fax:
Practice Address - Street 1:1940 BASELINE RD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2148
Practice Address - Country:US
Practice Address - Phone:909-392-1344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator