Provider Demographics
NPI:1942467956
Name:MARTELLY, EDEN GAIL
Entity Type:Individual
Prefix:MRS
First Name:EDEN
Middle Name:GAIL
Last Name:MARTELLY
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 1:26742 DULCINEA
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5923
Mailing Address - Country:US
Mailing Address - Phone:949-510-3625
Mailing Address - Fax:
Practice Address - Street 1:26742 DULCINEA
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5923
Practice Address - Country:US
Practice Address - Phone:949-510-3625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X, 101YM0800X
CA113328106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health