Provider Demographics
NPI:1649306184
Name:MARTIN, MANUEL L (MFT)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:L
Last Name:MARTIN
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:PO BOX 500713
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92150-0713
Mailing Address - Country:US
Mailing Address - Phone:760-415-0235
Mailing Address - Fax:
Practice Address - Street 1:2558 ROOSEVELT ST
Practice Address - Street 2:SUITE 203
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1672
Practice Address - Country:US
Practice Address - Phone:760-415-0235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29639106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health