Provider Demographics
NPI:1881187599
Name:MARTINEZ, INGRID LISSETH
Entity Type:Individual
Prefix:MS
First Name:INGRID
Middle Name:LISSETH
Last Name:MARTINEZ
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 1:21034 BRYANT STREET
Mailing Address - Street 2:APARTMENT 4
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304
Mailing Address - Country:US
Mailing Address - Phone:818-277-0273
Mailing Address - Fax:
Practice Address - Street 1:1400 S GRAND AVE STE 600
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3068
Practice Address - Country:US
Practice Address - Phone:213-742-6250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional