Provider Demographics
NPI:1992398861
Name:MARTINEZ, KELVIN (AMFT)
Entity Type:Individual
Prefix:
First Name:KELVIN
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1728 GLENDALE BLVD # 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-1738
Mailing Address - Country:US
Mailing Address - Phone:910-797-0708
Mailing Address - Fax:
Practice Address - Street 1:9350 WILSHIRE BLVD STE 212
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-3204
Practice Address - Country:US
Practice Address - Phone:910-797-0708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT124195106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist