Provider Demographics
NPI:1972824019
Name:MARTIN, PATRICK VINCENT (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:VINCENT
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1359 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-1016
Mailing Address - Country:US
Mailing Address - Phone:626-430-2900
Mailing Address - Fax:626-331-0035
Practice Address - Street 1:1359 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1016
Practice Address - Country:US
Practice Address - Phone:626-430-2900
Practice Address - Fax:626-331-0035
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-11
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31065101YM0800X
CA656081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health