Provider Demographics
NPI:1609201615
Name:KNUDSON-MARTIN, CARMEN
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:
Last Name:KNUDSON-MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:CARMEN
Other - Middle Name:
Other - Last Name:PTACEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:21121 NE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-6762
Mailing Address - Country:US
Mailing Address - Phone:909-262-7725
Mailing Address - Fax:
Practice Address - Street 1:21121 NE SHORE DR
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OR
Practice Address - Zip Code:97024-6762
Practice Address - Country:US
Practice Address - Phone:909-262-7725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0736106H00000X
CA40993106H00000X
GAMFT000876106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist