Provider Demographics
NPI:1831850486
Name:MARTIN, RASELINE
Entity type:Individual
Prefix:MRS
First Name:RASELINE
Middle Name:
Last Name:MARTIN
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 1:1910 S STAPLEY DR STE 221
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6680
Mailing Address - Country:US
Mailing Address - Phone:253-330-9604
Mailing Address - Fax:
Practice Address - Street 1:1910 S STAPLEY DR STE 221
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6680
Practice Address - Country:US
Practice Address - Phone:253-330-9604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH6889101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health