Provider Demographics
NPI:1790176030
Name:SHIPP, MARTINA DANIELLE
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:DANIELLE
Last Name:SHIPP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4403 LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94608-3419
Mailing Address - Country:US
Mailing Address - Phone:510-459-3173
Mailing Address - Fax:
Practice Address - Street 1:3900 VALLEY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-4871
Practice Address - Country:US
Practice Address - Phone:510-318-6137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101MY0800X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health