Provider Demographics
NPI:1881811420
Name:AYALA, MARTIN (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:
Last Name:AYALA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 GIOVANNE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-5701
Mailing Address - Country:US
Mailing Address - Phone:626-222-0911
Mailing Address - Fax:
Practice Address - Street 1:160 E HOLT AVE
Practice Address - Street 2:B
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5406
Practice Address - Country:US
Practice Address - Phone:909-620-2521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA282211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00007302Medicaid
CACBSC709OtherLA DMH PROVIDER