Provider Demographics
NPI:1255043758
Name:MARTIN, LISA MARIE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:TUCKERMARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3111 CAMINO DEL RIO N
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-5720
Mailing Address - Country:US
Mailing Address - Phone:888-922-2843
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:3111 CAMINO DEL RIO N
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-5720
Practice Address - Country:US
Practice Address - Phone:888-922-2843
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2022-12-16
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician