Provider Demographics
NPI:1295913952
Name:MARTINEZ, MONICA
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14223 DEMBLON ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-2660
Mailing Address - Country:US
Mailing Address - Phone:626-338-2625
Mailing Address - Fax:
Practice Address - Street 1:1501 HUGHES WAY STE 150
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90810-1878
Practice Address - Country:US
Practice Address - Phone:310-221-6336
Practice Address - Fax:310-868-5398
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF85689106H00000X
CAIMF59718106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIMF85689OtherBBS