Provider Demographics
NPI:1124275532
Name:MARTELLA, MICHAEL ALAN (MFT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALAN
Last Name:MARTELLA
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8058 LA MESA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-6435
Mailing Address - Country:US
Mailing Address - Phone:619-463-9742
Mailing Address - Fax:619-463-2522
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-6435
Practice Address - Country:US
Practice Address - Phone:253-968-2252
Practice Address - Fax:253-966-1127
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-27
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC20941106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist