Provider Demographics
NPI:1881001915
Name:MARTINEZ, KELLIANNE JANAE (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:KELLIANNE
Middle Name:JANAE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:KELLIANNE
Other - Middle Name:JANAE
Other - Last Name:MAHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:407 4TH ST APT F
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-4281
Mailing Address - Country:US
Mailing Address - Phone:707-849-0579
Mailing Address - Fax:
Practice Address - Street 1:512 TETON CT
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6641
Practice Address - Country:US
Practice Address - Phone:707-849-0579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA105824106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor