Provider Demographics
NPI:1740205186
Name:MARTIN, WILLIAM W (PHD,PC)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:W
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 CAMINO DE LOS MARES
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2859
Mailing Address - Country:US
Mailing Address - Phone:949-248-7377
Mailing Address - Fax:866-806-2796
Practice Address - Street 1:665 CAMINO DE LOS MARES
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2859
Practice Address - Country:US
Practice Address - Phone:949-248-7377
Practice Address - Fax:866-806-2796
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9840103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0295334OtherCOM VOC SRVS-WORK COMP