Provider Demographics
NPI:1609497023
Name:MARTINEZ CARLOS, LAUREN GISELLE
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:GISELLE
Last Name:MARTINEZ CARLOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:GISELLE
Other - Last Name:CARLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4688 ONTARIO MILLS PKWY
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-5104
Mailing Address - Country:US
Mailing Address - Phone:714-834-1111
Mailing Address - Fax:
Practice Address - Street 1:4688 ONTARIO MILLS PKWY
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5104
Practice Address - Country:US
Practice Address - Phone:714-834-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-27
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program