Provider Demographics
NPI:1649722216
Name:MARTIN, CHLOE A (PHD)
Entity type:Individual
Prefix:
First Name:CHLOE
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:CHLOE
Other - Middle Name:ANDRIVEAU
Other - Last Name:DRAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:148 HILLDALE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2320
Mailing Address - Country:US
Mailing Address - Phone:415-464-7149
Mailing Address - Fax:
Practice Address - Street 1:1030 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:SUITE 100, ROOM 1
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1411
Practice Address - Country:US
Practice Address - Phone:415-496-9033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19103103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical