Provider Demographics
NPI:1629306576
Name:LANDRUM, MARTHA BRIMBERRY (MFT)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:BRIMBERRY
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6707 EMBARCADERO DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-3382
Mailing Address - Country:US
Mailing Address - Phone:209-956-4240
Mailing Address - Fax:209-956-4245
Practice Address - Street 1:6707 EMBARCADERO DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-3382
Practice Address - Country:US
Practice Address - Phone:209-956-4240
Practice Address - Fax:209-956-4245
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC46497106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist