Provider Demographics
NPI:1790216463
Name:MARTINEZ, LISA MARIE (CCAPP A052051120)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:CCAPP A052051120
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 N SUNRISE WAY
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-5201
Mailing Address - Country:US
Mailing Address - Phone:760-770-2286
Mailing Address - Fax:
Practice Address - Street 1:191 N SUNRISE WAY
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-5201
Practice Address - Country:US
Practice Address - Phone:760-770-2286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA052051120171M00000X
CAA0502051120101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator