Provider Demographics
NPI:1720491764
Name:CORRELL, MARTA VAISBERG (LAC)
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:VAISBERG
Last Name:CORRELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 CYPRESS AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-3710
Mailing Address - Country:US
Mailing Address - Phone:831-419-6036
Mailing Address - Fax:
Practice Address - Street 1:2222 E CLIFF DR STE 216
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-4739
Practice Address - Country:US
Practice Address - Phone:831-419-6036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-07
Last Update Date:2014-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC-16116171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist