Provider Demographics
NPI:1841998416
Name:MARTINEZ, ANISSA
Entity type:Individual
Prefix:
First Name:ANISSA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 N HEATHDALE AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-1439
Mailing Address - Country:US
Mailing Address - Phone:626-824-3018
Mailing Address - Fax:
Practice Address - Street 1:510 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3017
Practice Address - Country:US
Practice Address - Phone:626-973-8123
Practice Address - Fax:626-974-8198
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X, 171M00000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator