Provider Demographics
NPI:1598440232
Name:MARTINEZ, IAN COWAN
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:COWAN
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANI
Other - Middle Name:
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7109 DANNY DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-5320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7109 DANNY DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-5320
Practice Address - Country:US
Practice Address - Phone:209-957-7777
Practice Address - Fax:209-473-3344
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician