Provider Demographics
NPI:1518264803
Name:MARTINEZ, EDREA DANETTE (APC)
Entity type:Individual
Prefix:
First Name:EDREA
Middle Name:DANETTE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8360 FAIR PINES LN
Mailing Address - Street 2:
Mailing Address - City:GARDEN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95633-9233
Mailing Address - Country:US
Mailing Address - Phone:801-870-8834
Mailing Address - Fax:
Practice Address - Street 1:8360 FAIR PINES LN
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95633-9233
Practice Address - Country:US
Practice Address - Phone:801-870-8834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7600310-6009101YM0800X
CA18125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health