Provider Demographics
NPI:1689292211
Name:MARTINO, JOELLE (PSYD)
Entity Type:Individual
Prefix:
First Name:JOELLE
Middle Name:
Last Name:MARTINO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JOELLE
Other - Middle Name:
Other - Last Name:GEORGEFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2708
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93011-2708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:223 E THOUSAND OAKS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-7708
Practice Address - Country:US
Practice Address - Phone:714-909-4126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31792103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist