Provider Demographics
NPI:1821242744
Name:MARTINEZ, TIFFANY ROSE NICOLE (LPT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ROSE NICOLE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 E SHIELDS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-7029
Mailing Address - Country:US
Mailing Address - Phone:559-229-9040
Mailing Address - Fax:559-229-9060
Practice Address - Street 1:3707 E SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-7029
Practice Address - Country:US
Practice Address - Phone:559-229-9040
Practice Address - Fax:559-229-9060
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 34123101YA0400X
CA34123167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)