Provider Demographics
NPI:1740041466
Name:MARTIN, CHARLETTE MARIE (MA)
Entity type:Individual
Prefix:
First Name:CHARLETTE
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:CHARLETTE
Other - Middle Name:MARIE
Other - Last Name:HULTQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:8872 DIAMONDBACK DR
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-3250
Mailing Address - Country:US
Mailing Address - Phone:619-508-2848
Mailing Address - Fax:
Practice Address - Street 1:8872 DIAMONDBACK DR
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3250
Practice Address - Country:US
Practice Address - Phone:619-508-2848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YS0200X
CA3188103TS0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool