Provider Demographics
NPI:1972929115
Name:MARTINEZ, LETICIA (PTA)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 S MOORPARK RD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1008
Mailing Address - Country:US
Mailing Address - Phone:805-413-0160
Mailing Address - Fax:805-413-0161
Practice Address - Street 1:343 S MOORPARK RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1008
Practice Address - Country:US
Practice Address - Phone:805-413-0160
Practice Address - Fax:805-413-0161
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA5589225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant