Provider Demographics
NPI:1598526956
Name:MULGADO, MARTHA A
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:A
Last Name:MULGADO
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 1:6040 JONES AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-1130
Mailing Address - Country:US
Mailing Address - Phone:951-465-9339
Mailing Address - Fax:
Practice Address - Street 1:6040 JONES AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-1130
Practice Address - Country:US
Practice Address - Phone:951-465-9339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY5817106106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician